The Brazilian Journal of Anesthesiology granted permission to reuse Table 1 and Figure 3.

The study, approved by the &#34;Iuliu Ha&#539;ieganu&#34; University of Medicine and Pharmacy Ethics Committee (no. 100/12.02.2018) and registered under ClinicalTrials.gov identifier NCT03546088, enrolled adult patients with ASA physical status I-IV8. These individuals had distorted airway anatomy due to laryngopharyngeal pathology and were scheduled for surgery under general anesthesia. Informed consent was obtained from all participants. The inclusion criteria were a Simplified Airway Risk Index...

Awake Intubation in Difficult Airways: A Flexible Video Laryngoscope Method

<ol>
	<li>Joffe, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+difficult+tracheal+intubation:+A+closed+claims+analysis.">Management of difficult tracheal intubation: A closed claims analysis.</a> Anesthesiology. 131 (4), 818-829 (2019).</li><li>Cook, T. M., Woodall, N., Frerk, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+complications+of+airway+management+in+the+UK:+Results+of+the+fourth+national+audit+project+of+the+Royal+College+of+Anaesthetists+and+the+difficult+airway+society.+Part+1:+Anaesthesia.">Major complications of airway management in the UK: Results of the fourth national audit project of the Royal College of Anaesthetists and the difficult airway society. Part 1: Anaesthesia.</a> Br J Anaesth. 106 (5), 617-631 (2011).</li><li>Rosenstock, C. V., N&#248;rskov, A. K., Wetterslev, J., Lundstr&#248;m, L. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+surgical+airway+management+in+Denmark:+A+cohort+study+of+452461+patients+registered+in+the+Danish+anesthesia+database.">Emergency surgical airway management in Denmark: A cohort study of 452461 patients registered in the Danish anesthesia database.</a> Br J Anaesth. 117 (Suppl 1), i75-i82 (2016).</li><li>Apfelbaum, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Society+of+Anesthesiologists+practice+guidelines+for+management+of+the+difficult+airway.">American Society of Anesthesiologists practice guidelines for management of the difficult airway.</a> Anesthesiology. 136 (1), 31-81 (2022).</li><li>Vora, J., Leslie, D., Stacey, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Awake+tracheal+intubation.">Awake tracheal intubation.</a> BJA Educ. 22 (8), 298-305 (2022).</li><li>Alvi, S., Harsha, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Flexible+Nasopharyngoscopy.">Flexible Nasopharyngoscopy.</a> Statpearls, StatPearls Publishing Copyright &#169; 2024. , (2024).</li><li>Paul, B. C., Rafii, B., Achlatis, S., Amin, M. R., Branski, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+and+patient+perception+of+flexible+laryngoscopy.">Morbidity and patient perception of flexible laryngoscopy.</a> Ann Otol Rhinol Laryngol. 121 (11), 708-713 (2012).</li><li>Marchis, I. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Awake+nasotracheal+intubation+with+a+300+mm+working+length+fiberscope:+A+prospective+observational+feasibility+trial.">Awake nasotracheal intubation with a 300 mm working length fiberscope: A prospective observational feasibility trial.</a> Braz J Anesthesiol. 73 (5), 556-562 (2023).</li><li>N&#248;rskov, A. K., Rosenstock, C. V., Wetterslev, J., Lundstr&#248;m, L. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+unanticipated+difficult+airway+using+an+objective+airway+score+versus+a+standard+clinical+airway+assessment:+The+difficult+trial+-+trial+protocol+for+a+cluster+randomized+clinical+trial.">Incidence of unanticipated difficult airway using an objective airway score versus a standard clinical airway assessment: The difficult trial - trial protocol for a cluster randomized clinical trial.</a> Trials. 14, 347 (2013).</li><li>Marchis, I. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trends+in+preoperative+airway+assessment.">Trends in preoperative airway assessment.</a> Diagnostics. 14 (8), 610 (2024).</li><li>Lin, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point-of-care+ultrasound+in+airway+evaluation+and+management:+A+comprehensive+review.">Point-of-care ultrasound in airway evaluation and management: A comprehensive review.</a> Diagnostics. 13 (9), 1541 (2023).</li><li>Marchis, I. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> New methods of controlling the difficult airway in otorhinolaryngologic anesthesia—PhD Thesis, Cluj Napoca. , (2022).</li><li>Fiadjoe, J. E., Litman, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Difficult+tracheal+intubation:+Looking+to+the+past+to+determine+the+future.">Difficult tracheal intubation: Looking to the past to determine the future.</a> Anesthesiology. 116 (6), 1181-1182 (2012).</li><li>Joseph, T. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+retrospective+study+of+success,+failure,+and+time+needed+to+perform+awake+intubation.">A retrospective study of success, failure, and time needed to perform awake intubation.</a> Anesthesiology. 125 (1), 105-114 (2016).</li><li>Asai, T., Shingu, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Difficulty+in+advancing+a+tracheal+tube+over+a+fibreoptic+bronchoscope:+Incidence,+causes+and+solutions.">Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: Incidence, causes and solutions.</a> Br J Anaesth. 92 (6), 870-881 (2004).</li><li>Ahmad, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Difficult+airway+society+guidelines+for+awake+tracheal+intubation+(ati)+in+adults.">Difficult airway society guidelines for awake tracheal intubation (ati) in adults.</a> Anaesthesia. 75 (4), 509-528 (2020).</li><li>Jones, T. M., De, M., Foran, B., Harrington, K., Mortimore, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laryngeal+cancer:+United+Kingdom+national+multidisciplinary+guidelines.">Laryngeal cancer: United Kingdom national multidisciplinary guidelines.</a> J Laryngol Otol. 130 (S2), S75-S82 (2016).</li><li>Rosenblatt, W., Ianus, A. I., Sukhupragarn, W., Fickenscher, A., Sasaki, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+endoscopic+airway+examination+(PEAE)+provides+superior+airway+information+and+may+reduce+the+use+of+unnecessary+awake+intubation.">Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation.</a> Anesth Analg. 112 (3), 602-607 (2011).</li><li>Tsunoda, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+videoendoscopic+endonasal+tracheal+intubation+for+severe+upper+airway+stenosis.">Emergency videoendoscopic endonasal tracheal intubation for severe upper airway stenosis.</a> Am J Otolaryngol. 42 (2), 102779 (2021).</li><li>Kramer, A., M&#252;ller, D., Pf&#246;rtner, R., Mohr, C., Groeben, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibreoptic+vs.+videolaryngoscopic+(c-mac+d-blade)+nasal+awake+intubation+under+local+anaesthesia.">Fibreoptic vs. videolaryngoscopic (c-mac d-blade) nasal awake intubation under local anaesthesia.</a> Anaesthesia. 70 (4), 400-406 (2015).</li></ol>

There are several reasons why awake fiberoptic intubation is a relatively uncommon practice: it seems challenging to learn, the skill requires regular training to maintain proficiency, or a previous bad experience with this technique combined with the reluctance of an awake patient about the procedure13,14.
When using a 600 mm fiberscope, the practitioners concentrate on how to hold the fiberscope in position, which may dilute their fo...

Airway management has developed substantially over the last 20 years, but difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality1. Patients with known or unknown pathologies of the base of the tongue, hypopharynx, glottic aperture, or trismus pose a risk of difficult or impossible facemask ventilation, supraglottic device placement, and tracheal intubation after the induction of general anesthesia1,2,3.
Standard preoperative airway examinations often fail to reveal these lesions due to discrete accompanying clinical signs and symptoms2,3. Awake flexible scope intubation is considered the gold standard in securing the airway in such cases because it allows for spontaneous respiration, preserves airway reflexes, and mitigates the risks of losing the airway or bronchopulmonary aspiration4. Despite its benefits, awake intubation remains an underused technique, even when indicated (around 1% of all intubations), due to reservations regarding its use related to lack of practice or the pressure of a busy operating theatre2,4. With the development of airway control devices, awake intubation now includes procedures employing flexible scopes, rigid or semirigid optical stylets, and video laryngoscopes5.
Nasopharyngeal flexible endoscopy, sometimes referred to as flexible nasopharyngoscopy, flexible nasolaryngoscopy, transnasal flexible laryngoscopy, or flexible fiberoptic nasopharyngolaryngoscopy, is a medical technique that aids the practitioner in examining the nasal passages, nasopharynx, oropharynx, hypopharynx, and larynx6. It is a routine instrument in ENT (ear, nose, and throat) practice and has the advantage of being minimally invasive and easy to handle7. Its use has expanded across different medical specialties, including maxillofacial surgery, anesthesiology, speech and language therapy, and neurology. In an office or hospital setting, flexible rhinolaryngoscopy provides a valuable assessment of the airway and alerts healthcare providers to the presence of pathological pharyngolaryngeal structures that may impact airway management.
The flexible fiberoptic endoscope used for the adult population has a rigid part designed to be used with one hand and a flexible fiber optic cable. The effective length of the scope is between 300 and 350 mm with a flexibility of 130&#730; to 160&#730;. The flexible tip has a length of 20 mm with a visualization angle of 80&#730; to 90&#730; in newer models. The depth of field can be easily adjusted with the handpiece roller, ranging from 3 to 60 mm. The diameter of the insertion tube may range from 3 mm to 4.5 mm, and certain models are equipped with a working or suction channel (Figure 1). Technology has advanced further, and the device has evolved from fiberoptic to new chip-on-the-tip flexible digital scopes, ensuring high-resolution imaging6,7.
Traditionally, practitioners perform awake flexible scope intubation using a fiberoptic bronchoscope with a 600 mm working length5. This protocol, based on a previous prospective study8, aims to describe in detail a technique for awake nasotracheal intubation using a 300 mm flexible rhino-laryngoscope.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Anesthesia machinne</td>
			<td>Draeger Fabius Plus</td>
			<td>1x RS232</td>
			<td></td>
		</tr>
		<tr>
			<td>Cricothyrotomy Kit</td>
			<td>CHINOOK MEDICAL GEAR, INC</td>
			<td>2160-36401</td>
			<td></td>
		</tr>
		<tr>
			<td>Ephedrine 50 mg/mL</td>
			<td>Zentiva</td>
			<td>59447636327627</td>
			<td></td>
		</tr>
		<tr>
			<td>Epinephrine 1 mg/mL</td>
			<td>Terapia SA</td>
			<td>5944702207310</td>
			<td></td>
		</tr>
		<tr>
			<td>Face mask nebulizer</td>
			<td>Ningbo Luke Medical devices</td>
			<td>RT012-100</td>
			<td></td>
		</tr>
		<tr>
			<td>Fentanyl 0.05 mg/mL</td>
			<td>Chiesi</td>
			<td>W58348002</td>
			<td></td>
		</tr>
		<tr>
			<td>flexible extension corrugated tube -catheter mount</td>
			<td>Ningbo Yingbe Medical Instruments</td>
			<td>YM-A040</td>
			<td></td>
		</tr>
		<tr>
			<td>Irrigation cannula</td>
			<td>Carl Roth</td>
			<td>HPY 2.1</td>
			<td>blunt tip, curved, 80 mm long irrigation cannula suitable for airway topicalisation</td>
		</tr>
		<tr>
			<td>Lidocaine 2%, 4%</td>
			<td>Zentiva</td>
			<td>5944705004046</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine gel 2%</td>
			<td>Montavit</td>
			<td>9001505008066</td>
			<td></td>
		</tr>
		<tr>
			<td>Lidocaine spray 10%</td>
			<td>Egis&#160;</td>
			<td>5995327112169</td>
			<td></td>
		</tr>
		<tr>
			<td>Midazolam 5 mg/mL</td>
			<td>Aquetant</td>
			<td>P438804058</td>
			<td></td>
		</tr>
		<tr>
			<td>Reinforced endotracheal tubes oral/nasal</td>
			<td>Create Biotech L</td>
			<td>019-002-1065</td>
			<td></td>
		</tr>
		<tr>
			<td>TelePack X Led Monitor</td>
			<td>Karl Storz</td>
			<td>200450 20</td>
			<td>HIGH RESOLUTION MONITOR, LED LIGHT SOURCE, FULL HD CAMERA CONTROL UNIT&#160;</td>
		</tr>
		<tr>
			<td>Video Rhino-Laryngoscope</td>
			<td>Karl Storz</td>
			<td>11101 VP</td>
			<td>Video Rhino-Laryngoscope direction of view 0&#176;, angle of view 85&#176;, deflection up/down 140&#176;/140&#176;, working length 30 cm</td>
		</tr>
		<tr>
			<td>Vital signs monitor</td>
			<td>Mindray</td>
			<td>N17- E392290</td>
			<td></td>
		</tr>
		<tr>
			<td>Xylometazoline 1 mg/mL</td>
			<td>Biofarma</td>
			<td>59463429</td>
			<td></td>
		</tr>
	</tbody>
</table>

the flexible rhino-laryngoscope for awake nasotracheal intubation

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies obstructing airway access are at risk of airway management failure once they lose spontaneous respiration. Awake flexible scope intubation is considered the gold standard for controlling the airway in such patients. Following a feasibility trial involving 25 patients with challenging airways, this article presents a step-by-step protocol for awake nasotracheal intubation using a flexible video rhino-laryngoscope, which is significantly shorter than conventional intubating flexible scopes. The flexible video laryngoscope only exceeds the intubating tube length by a few centimeters, allowing the tube to closely follow the flexible scope during the procedure. Once the scope reaches the pharynx, it can be easily manipulated with one hand, enabling the operator to focus on the safe advancement of the scope-intubating tube assembly through the glottis. Based on previous results and experience gained, this article highlights the potential benefits of the technique: the opportunity for a minimally invasive "quick look" preoperatively to establish a final management plan, a more convenient and safer tool for navigating distorted anatomy with a lower chance of intubating tube impingement and airway injury, and a fast and smooth procedure resulting in improved patient satisfaction.

Author Spotlight: Advancing Awake Nasotracheal Intubation with Flexible Video Rhino-Laryngoscopes

The Flexible Rhino-Laryngoscope for Awake Nasotracheal Intubation

This study aims to provide a comprehensive description of the awake nasotracheal intubation technique using a flexible rhino-laryngoscope. We propose that this method could serve as a safe, simple, and economical alternative to the conventional fiber optic bronchoscope. Despite its recognized benefits, awake intubation remains underused in clinical practice.This research aims to investigate whether the shorter, flexible scope can make the procedure more accessible and practical, encouraging its broader adoption. A shorter scope can improve maneuverability and decrease the likelihood of buckling. It can be operated with one hand, freeing the other to adjust the patient's head.It aids in the proper alignment of the scope with the glottis, allowing for the operator to focus on the anatomical landmarks when navigating towards the trachea. The flexible rhino-laryngoscope could be a significant asset to the airway management toolkit for anesthesia providers, offering benefits for the assessment and management of patients with difficult airways.

This article aims to describe in detail a technique for awake nasotracheal intubation using a 300 mm flexible rhino-laryngoscope. In the first study, 25 out of 32 consecutive patients, aged between 34 years and 82 years, were considered suitable for awake tracheal intubation and included in the trial (Table 1)8. Each patient&#39;s trachea was successfully intubated using a flexible rhino-laryngoscope. The average &#177; standard deviation duration from the insertion of the intubat...

Presented here is a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope with a 300 mm working length. As this tool is minimally invasive and easy to manipulate, awake intubation performed with a flexible rhino-laryngoscope is well-tolerated, fast, and safe for patients with difficult airways.

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies ...

the-flexible-rhino-laryngoscope-for-awake-nasotracheal-intubation

Research

JoVE Journal

Medicine

Awake Intubation with a Compact Video Laryngoscope to Secure the Airway

To begin, position the patient on the operating table in a sitting or semi-recumbent position. Perform the American Society of Anesthesiologists Defined Monitoring Procedure. Evaluate the airway using a 300 to 350-millimeter working length flexible video rhinolaryngoscope with the most suitable nostril for ETT placement.Check for septal deviation, bony spurs, and turbinate hypertrophy. Inspect the pharynx and the paraglottic space, vocal cords and subglottic region to the mid-trachea. Using the working channel of the scope or a curved oropharyngeal catheter under fiber optic guidance, administer lidocaine topically, dripping over the glottis and the vocal cords.Start the maneuver with the flexible rhinolaryngoscope. Armed with an intubating tube. Use 2%Lidocaine gel to lubricate a reinforced cuffed ETT with an internal diameter of 5.5 to 6.5 millimeters.Place the fibroscope inside the ETT, ensuring that the proximal end of the tube covers the transitional part of the fibroscope handle. Introduce the fibroscope ETT ensemble in the selected nostril. Orient the bevel of the ETT laterally during the nasal passage, then slowly advance following the nasal floor and the septum.Rotate the tube with small movements if an obstacle is encountered during the nasal passage. When the scope reaches the pharynx, stop the advancement and search for epiglottis, arytenoids, or vocal cords. Advance the tube to the mid-tracheal level.After confirming proper tube placement with the tip two to four centimeters above the carina With fiber optic visualization, remove the fibroscope. Then connect the patient to the ventilator to ensure proper capnography waveform and spontaneous movement of the ventilation bag. Secure the ETT in position with tape and use a flexible extension corrugated tube to connect the ETT to the breathing circuit.The average duration from the insertion of the intubating tube through one nostril to the confirmation of endotracheal intubation was around 76 seconds.

263 Views.  “Iuliu Haţieganu” University of Medicine and Pharmacy.  Presented here is a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope with a 300 mm working length. As this tool is minimally invasive and easy to manipulate, awake intubation performed with a flexible rhino-laryngoscope is well-tolerated, fast, and safe for patients with difficult airways.

Awake Intubation in Difficult Airways: A Flexible Video Laryngoscope Method

Summary