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Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway

A Systematic Review and Meta-analysis of Randomized Controlled Trials

Cabrini, Luca, MD*,†; Baiardo Redaelli, M, MD*; Ball, Lorenzo, MD; Filippini, Martina, MD*; Fominskiy, Evgeny, MD*; Pintaudi, Margherita, MD*; Putzu, Alessandro, MD§; Votta, Carmine D., MD*; Sorbello, Massimiliano, MD; Antonelli, Massimo, MD; Landoni, Giovanni, MD*,†; Pelosi, Paolo, MD; Zangrillo, Alberto, MD*,†

doi: 10.1213/ANE.0000000000004087
Respiration and Sleep Medicine: Systematic Review Article

Awake fiberoptic intubation is one of the recommended strategies for surgical patients with anticipated difficult airway, especially when concurrent difficult ventilation is expected. We performed the first systematic review of randomized controlled trials assessing different protocols for awake fiberoptic intubation in anticipated difficult airway, including studies investigating elective awake fiberoptic intubation for scheduled surgery; randomized controlled trials comparing different methods for performing awake fiberoptic intubation; and adult patients with anticipated difficult airway. We excluded studies in the nonoperating theater settings, randomized controlled trials comparing awake fiberoptic intubation with other techniques, and studies based on simulation. Primary outcomes were success rate and death; secondary outcomes were major adverse events. Thirty-seven randomized controlled trials evaluating 2045 patients and 4 areas were identified: premedication, local anesthesia, sedation, and ancillary techniques to facilitate awake fiberoptic intubation. Quality of evidence was moderate–low and based on small-sampled randomized controlled trials. Overall, 12 of 2045 intubation failures (0.59%) and 7 of 2045 severe adverse events (0.34%) occurred, with no permanent consequences or death. All evaluated methods to achieve local anesthesia performed similarly well. No differences were observed in success rate with different sedatives. Dexmedetomidine resulted in fewer desaturation episodes compared to propofol and opioids with or without midazolam (relative risk, 0.51 [95% CI, 0.28–0.95]; P = .03); occurrence of desaturation was similar with remifentanil versus propofol, while incidence of apnoea was lower with sevoflurane versus propofol (relative risk, 0.43 [95% CI, 0.22–0.81]; P = .01). A high degree of efficacy and safety was observed with minimal differences among different protocols; dexmedetomidine might offer a better safety profile compared to other sedatives.

From the *Department of Anaesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy

Università Vita-Salute San Raffaele, Milan, Italy

Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology, University of Genoa, Genoa, Italy

§Division of Anesthesiology, Department of Anesthesiology, Pharmacology & Intensive Care Medicine, Geneva University Hospitals, Geneva, Switzerland

Anaestesia and Intensive Care, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele, Catania, Italy

Department of Intensive Care Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy.

Published ahead of print 16 January 2019.

Accepted for publication January 16 2019.

Funding: Institutional.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Registration: Prospero CRD42018093009.

Reprints will not be available from the authors.

Address correspondence to Paolo Pelosi, MD, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l’Oncologia, Largo Rosanna Benzi 8, 16131 Genoa, Italy. Address e-mail to

© 2019 International Anesthesia Research Society
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