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Awake Fiberoptic Intubation in Fast Track Ambulatory Surgery: A Case Report

Hannig, Kjartan E. MD*; Jessen, Christian MD; Hauritz, Rasmus W. MD*; Grejs, Anders M. MD, PhD

doi: 10.1213/XAA.0000000000000863
Case Reports

An increasing number of surgical procedures are performed in the ambulatory setting, leading to improved patient comfort and cost-effectiveness. Patients with suspected or known difficult airways represent a challenge when anesthetized. This may explain why this patient group may be rejected for day-case surgery. We present 3 cases scheduled for day-case procedures with predicted difficult airways, where the feasibility of awake fiberoptic intubation is demonstrated in a Scandinavian fast track setting. Our hypothesis is that, with accurate preparations, intubation times are comparable with conventional intubation and that the procedure is associated with only minor patient discomfort.

From the *Department of Anesthesiology, Kolding Hospital, Kolding, Denmark

Department of Anesthesiology, Horsens Hospital, Horsens, Denmark

Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.

Accepted for publication July 3, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Kjartan E. Hannig, MD, Department of Anesthesiology, Kolding Hospital, Sygehusvej 24, 6000 Kolding, Denmark. Address e-mail to

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

In Denmark, 60%–70% of all operations are scheduled for ambulatory surgery,1 involving a team consisting of anesthesiologist, specially trained anesthesia nurse, and postanesthesia care unit (PACU) nurse. While the number of surgical procedures on inpatients was largely unchanged from 2006 to 2016, the ambulatory procedures almost doubled.1

Patients with suspected or known difficult airways comprise a challenge when anesthetized and additional time for the anesthetic procedure may be needed. Accordingly, these patients may be rejected for day-case surgery in some health care systems.

We present 3 cases illustrating that awake fiberoptic intubation (FOI) in a Scandinavian day-case setting is as fast as conventional intubation without significant self-reported patient discomfort. To the best of our knowledge, this is the first report on the use of FOI in an ambulatory fast track setting with corresponding intubation times.

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Written informed consent for publication was obtained from all patients. Approval from The Central Denmark Region Committee on Health Research Ethics was unnecessary.

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Patient 1

A 74-year-old woman with a Simplified Airway Risk Index (SARI) score2 of 7 presented for colonoscopic polypectomy. She was known with hypertension and reflux caused by a hiatus hernia.

On arrival at the PACU, an intravenous (IV) line was placed and standard monitoring including pulse oximetry, electrocardiography, and blood pressure measurement was started. Thirty minutes before surgery, intermittent preparations were started in the PACU by the anesthesiologist and, from that point, a PACU nurse was in the immediate vicinity of the patient. Glycopyrrolate 0.2 mg IV (Meda, Solna, Sweden) was administered once. Sedation was started with midazolam 0.5–1 mg (Hameln, Hameln, Germany) IV repeatedly at 5-minute intervals (total dose 2.5 mg). Airway topicalization was initiated with lidocaine 10% (AstraZeneca, Södetälje, Sweden) sprayed to the base of the tongue and posterior pharynx subsequently deeper 3 times with 2–3 minutes apart (total dose 90 mg). Lidocaine 2% (Mylan, Canonsburg, PA ) 4 mL was inhaled using a nebulizer. This was done twice at 10-minute intervals (total dose 160 mg). The sedation and airway topicalization were performed by the anesthesiologist and timed, so the patient was slightly sedated and optimally local anesthetized when taken to the operating room (OR). Here the semisitting position provided airway patency. Oxygen 3 L·minute−1 was administered by a nasal catheter, and continuous remifentanil (B. Braun, Melsungen, Germany) was started at a rate of 0.05 µg·kg−1·minute−1 (total dose 27 µg). The anesthesiologist was facing the patient, ensuring eye contact and continued to titrate sedation to a level 2 on the Ramsey scale, so the patient was cooperative and oriented. FOI was uneventful with a Rusch (Teleflex, Wayne, NJ) endotracheal tube with an internal diameter of 7.0 mm using the aScope Regular (Ambu, Ballerup, Denmark) 9 minutes after entering the OR. Tube placement was confirmed visually and with capnography. Subsequently, a bolus of 140 mg of propofol (Fresenius Kabi, Bad Homburg, Germany) was administered ensuring that general anesthesia was maintained with propofol and remifentanil infusion. The surgery, extubation, and PACU stay were uneventful.

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Patient 2

A 71-year-old man (SARI2 6) was scheduled for laparoscopic cholecystectomy. He was healthy and did not take any medication.

As in patient 1, an IV line was placed, standard monitoring started, and glycopyrrolate administered. To prevent excess opioid administration perioperatively, an erector spinae plane block was performed.3 Midazolam administration (total dose 1.5 mg) and airway topicalization with lidocaine (total dose 250 mg) in the PACU were similar to patient 1. Once in the OR, remifentanil was infused (total dose 26 µg) and FOI succeeded 10 minutes after the patient entered the OR. Surgery and extubation were uneventful. The first Numerical Rating Scale for abdominal pain was 0 and the highest Numerical Rating Scale while in the PACU was 4.

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Patient 3

A 58-year-old man (SARI2 7) presented for a laparoscopic inguinal hernia procedure. His comorbidity included obesity and asthma.

Preoperative preparations in the PACU were similar to patients 1 and 2 (total dose midazolam 3 mg and lidocaine 250 mg). Once in the OR, remifentanil was infused (total dose 34 µg) and, in this case, transtracheal administration of lidocaine 4% 1 mL was also done (total dose 40 mg). Intubation was performed 9 minutes after entering the OR. Extubation and PACU stay were uncomplicated.

Table 1.

Table 1.

Table 2.

Table 2.

Tables 1 and 2 summarize data from all cases.

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Guidelines on management of the difficult airway have been published in the United States, the United Kingdom, and Canada, among other countries.4 American and Canadian guidelines acknowledge FOI as a safe choice when difficulties with intubation are anticipated and especially when the risk of failure to succeed with backup plans for oxygenation by facemask or supraglottic device placement is considered high.4 The safety benefits of an awake approach include maintenance of airway patency, oxygenation, and protection against aspiration.4 Presence of obstructing airway pathology, risk of rapid desaturation (eg, morbid obesity), and increased risk of aspiration favor the awake approach.4 No indicators for potential difficult airway have been found to be fully reliable.5 Despite that, we decided to use the SARI2 because it is part of the clinical practice in our department and used very regularly worldwide.5

The main objective in all airway management is to avoid the “cannot intubate, cannot ventilate” situation, because emergency surgical airway attempts fail in 50%–65% of patients when performed by an anesthesiologist.6,7 Most important, 75% of patients undergoing emergency surgical airway had ear, nose, and throat (ENT) surgery before the event.6

Since the 1970s, awake FOI has been “the gold standard” for managing the anticipated difficult airway.4,8 In 2001, the first video laryngoscope (VL) was introduced and its use for awake intubation has been described in recent years with similar success rates as the fiberscope.8 Some authors believe that the VL should replace awake FOI.9 Other authors argue that FOI may be the only possible option in case of uniquely altered anatomy (eg, severely limited mouth opening, ENT tumors in the oral cavity, and upper airway or previous radiation), which may preclude lack of space for inserting the VL blade or impede the vision with the VL10. Approximately 20 mm mouth opening is required to reliably use VL for intubation orally.11

Awake FOI in postradiotherapy of patients with ENT cancer in the ambulatory setting has previously been described, regrettably without intubation times.12

At least 3 myths about awake FOI exist, which may cause the anesthesiologist to decline this approach: (1) it is time consuming; (2) it is uncomfortable for the patient; and (3) it is a difficult skill to learn and potentially unsafe.7,10

A retrospective study including 1085 awake FOI demonstrated that median time to intubation from entrance into the OR was 24 minutes, the corresponding time being 16 minutes for intubation after induction.10 In our day-case facility, a small unpublished survey demonstrated that conventional intubation after induction on average was done 14 minutes after the patient entered the OR. In this time, the OR staff welcomed the patient; the World Health Organization Surgical Safety Checklist was approved; an IV line was started; standard monitoring was ensured; preoxygenation, induction of anesthesia, and intubation were performed. When we performed the awake FOI, most of the preparations were performed in the PACU including application of an IV line and standard monitoring, airway topicalization, and start of sedation (approximately 10 minutes spent over a 30-minute period). Time from entering the OR to intubation was 10 minutes or less, giving 4–5 minutes less surgical “down time.” The awake FOI procedure in itself took <2 minutes.

The 3 patients rated the experience as causing slight discomfort, which corresponds to earlier reports.8

In patients with normal laryngeal anatomy, an acceptable level of technical skills may be achievable after 10 FOIs in general anesthesia and 15–20 on awake patients.9,13 It is a skill that needs to be practiced, since proficiency will deteriorate.8,9,14 Reported complications with awake FOI are low and comparable to conventional intubation.10,13

Management of difficult airways should only be performed in any clinical setup, where additional anesthesiologists also highly skilled in airway management are close by, special devices and backup strategies are present, and optimally when ENT surgical backup is readily available. Extreme precautions must be taken in patients with neck abnormalities (eg, previous ENT surgery, mass, and/or radiation).4,6,7 Thus, our approach cannot be translated directly in every ambulatory setting.

In all patients with difficult airways, focus should be on optimal extubation strategies because extubation can be just as critical as intubation.15 Patients should be preoxygenated with 100% oxygen and placed upright, spontaneous ventilation should be established, and the tube should be removed in the fully awake patient.15 Pain should ideally be treated with opioid-sparing techniques (eg, regional anesthesia), as high doses of opioids can lead to drowsiness, respiratory impairment, and postoperative nausea and vomiting. Both diminished consciousness and vomiting can potentially compromise the airway.

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These 3 cases illustrate that awake FOI can be performed safely in the fast track ambulatory surgical setting. Provided proper preoperative preparations in a setup with a specially trained anesthesia nurse and a PACU nurse, intubation times equal conventional intubation and self-reported patient discomfort is minor.

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The authors would like to thank Steffen Christensen, MD, PhD, for thorough proof reading of the manuscript.

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Name: Kjartan E. Hannig, MD.

Contribution: This author helped perform the procedures and write the manuscript.

Name: Christian Jessen, MD.

Contribution: This author helped write the manuscript.

Name: Rasmus W. Hauritz, MD.

Contribution: This author helped write the manuscript.

Name: Anders M. Grejs, MD, PhD.

Contribution: This author helped write the manuscript.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.