Flexible Fiberoptic Bronchoscopy or Video-Assisted Laryngoscopy?

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Introduction

Tracheal intubation is one of the most important skills for an anesthesiologist to master. It is imperative to be facile with a variety of methods to secure the airway in order to tailor your chosen technique based on patient factors and the clinical situation. Emergency intubations in a non-OR setting are fraught with potential complications and pose significant and life-threatening challenges. Often there is little time to gather information and generate a comprehensive plan for intubation.

Non-OR airway management (NORAM) in the ICU, emergency department, radiology procedure rooms, the floor and other remote locations within the hospital are far away from easy access to airway equipment, adequate assistance or proper monitoring.¹ These patients are typically critically ill are often in extremis, with very little physiologic reserve compared with the typical elective surgical patient.¹ Schwartz et al reported the rate of intubation failure in NORAM being as high as 11%, which is 10 times higher than failed intubation during emergency in-OR intubation.² Adverse outcomes in NORAM have been reported to be as high as 45.2%.³ Russotto et al found that hypoxemia, cardiovascular instability and cardiac arrest during NORAM occur at rates of 42.6%, 9.3% and 3.1%, respectively.³

Avoiding a situation that may become a “can’t ventilate, can’t intubate” scenario is paramount, although rare, occurring in less than one in 5,000 general anesthetics. The consequences of loss of the airway can be profound, with long-term morbidity, and is associated with 25% of deaths related to anesthesia.^4-7 It is imperative that anesthesia providers have ready access and understand the role that airway equipment, such as bougies, laryngeal mask (LM) airways, oropharyngeal and nasopharyngeal airways, flexible fiberoptic bronchoscopes and video laryngoscopes (VL) play both in and out of the OR. Rapid access to such equipment and the ability to execute a management schema during NORAM is paramount to reducing catastrophic complications.

One of the challenges of NORAM is the hemodynamic consequences of using induction agents to facilitate airway management. Propofol, while frequently used in the OR for hemodynamically stable patients, can have detrimental hemodynamic consequences. Ketamine, an NMDA (or N-methyl-D-aspartate) receptor antagonist, preserves the respiratory drive at sub-induction doses while producing hypnosis, and usually does not cause hypotension due to its sympathomimetic effect; however, if the patient is catecholamine-depleted, hemodynamic instability can occur. Ketamine can also increase airway secretions, making flexible fiberoptic bronchoscopy (FFB) difficult. Etomidate is an alternative that has been used in hemodynamically unstable patients, but its association with adrenal insufficiency and increased mortality should be considered when selecting an airway management plan.⁸ While none is the panacea, the dosing regimen is typically much lower in NORAM than the elective OR setting.

The approach to induction in the NORAM patient varies by practitioner, who may prescribe by a “recipe” that is similar for all patients or provide a customized “cocktail” based on the clinical situation. For example, a pre-set regimen of agents (0.1-0.2 mg/kg etomidate + 0.6 mg/kg rocuronium or 2-5 mg midazolam + 0.6-1 mg/kg rocuronium) may suit some providers. Conversely, an individualized regimen may be based on the airway team’s judgment, experience and skill set coupled with the patient’s primary underlying diagnosis, reason for mechanical support, comorbidities, current and anticipated hemodynamic picture, mental status and cooperation, as well as concern for the presence of known or suspected difficult airway traits/characteristics.

A possible alternative to potentially alleviate the hemodynamic consequences of induction is to perform NORAM awake with topical local anesthesia (TLA) alone or with light sedation (TLAS). Awake TLA would avoid altogether or markedly reduce the dosing of induction agents that contribute to hemodynamic alteration while maintaining spontaneous ventilation, and affording, for example, a neurologic assessment for the stroke patient (post-intubation, avoiding neuromuscular blocking [NMB] agent reversal) or maintaining spontaneous ventilation to reduce further cardiopulmonary compromise in the patient with cardiac tamponade or intermediate/high risk pulmonary embolism.

When a clinical decision for an awake intubation has been deemed appropriate due to concerns about a difficult airway, most probably, reflexively, many practitioners may conclude FFB as the only option. Although awake FFB is the gold standard, certain airway concerns can be managed by alternative approaches. Awake VL is another potential viable method.

With proper TLA/TLAS, even conventional direct laryngoscopy (DL) with or without bougie intubation is possible and will allow a much more hemodynamically stable intubation, in contrast to performing intubation after induction of general anesthesia, especially in NORAM, where patients may be in critical condition with severe comorbidities.

The goal of this review is to determine the feasibility of awake VL as a viable alternative to awake NORAM FFB.

Pros and Cons of Both Modalities

FFB is a very effective means of securing the airway and is considered the gold standard for awake intubations; however, it requires proper training to be successful, and about 20 awake FFB intubations are needed to develop the basic psychomotor skills to be proficient.⁹ Furthermore, if not using FFB intubation regularly, Latiff et al found that skills start to decline after two months.¹⁰ In the past, FFB intubation has been taught extensively during training; however, with increased availability of VL, trainees are not using fiberoptic intubation as often for challenging airways, and so their experience undergoes decay.¹¹ FFB intubation is also expensive and can be extremely difficult if there is blood or secretions in the airway.⁹

VL is relatively inexpensive compared with FFB and is often a better alternative in the presence of airway blood or secretions.¹² The VL blade requires similar psychomotor skill as DL and thus has a much less steep learning curve than FFB, requiring only about five intubations to be proficient.¹³ Having said that, many more are required with ongoing instruction and improvements in one’s technique to attain competency or an expert level VL skillset. Similar to DL, the VL blade can be used to lift and direct excessive tissue mechanically to achieve a better view.¹²

Many are proposing that VL be the new standard for intubating challenging airways; therefore, trainees are very experienced in this technique.¹¹ VL has become a popular approach that increases first-pass success during emergent and challenging intubations.¹⁴ Alhomary et al reported no significant difference in success rates between TLA–awake FFB intubation and TLA–awake VL, and found shorter intubation times with TLA–awake VL than with TLA–awake FFB.¹²

With technological advances, access to a combination device offering both VL and FFB on the same workstation is available. Providers have the ability to use both at the same time, with both views on the video screen. This can be very helpful with anatomically challenging airways. Commercially available single-use bronchoscopes include the Verathon BFlex and the Ambu aScope. Other features of these devices include availability in multiple sizes for different-sized endotracheal tubes (ETTs) and varying clinical situations, and they are often integrated on the same workstation as the VL devices (Verathon) or may be attached to a pole/tower (Ambu). This simplifies the NORAM equipment to a single system with both a VL and bronchoscope.¹⁵ An example of the system similar to what is used at Hartford Hospital is shown in Figure 1.

Airway Topicalization

An alternative approach to pharmacologic induction to facilitate airway management in the emergent setting is TLA of the orohypopharynx and upper airway. For one to perform airway topicalization, it helps to review the innervation of the airway (Figure 2).¹⁶ The glossopharyngeal nerve innervates the posterior third of the tongue, tonsils, vallecula and anterior epiglottis.⁸ The internal branch of the superior laryngeal nerve (a branch of the vagus nerve) innervates the area in the larynx above the vocal cords, which includes the base of the tongue, posterior epiglottis, aryepiglottic folds and arytenoids.⁸ The recurrent laryngeal nerve (also a branch of the vagus nerve) innervates the vocal cords themselves and the area in the larynx that lies below the vocal cords.⁸

Lidocaine 4% solution is commonly used for airway topicalization in the form of a solution or gel. There is also a lidocaine 10% spray. The oropharynx is prepared by drawing up lidocaine solution into a syringe and spraying it directly into the oropharynx. Depending on the patient’s cooperation and mental status, gargling and swallowing may be possible. More commonly, the emergent/urgent NORAM patient has some alteration in their mental status and likely will not follow simple directions. Liberal application, and allowing a few moments to pass to afford LA onset, is an easy alternative. In the NORAM setting, precise TLA application is typically not possible, as compared to elective TLA patient preparation.

If copious secretions are present, it is best to perform suction removal prior to TLA application. Also, allow the TLA to “percolate” for 30-60 seconds. Avoid immediate suctioning of the airway, to retain the TLA that was just applied. Soiled and bloody airways do not always provide the best TLA results since the TLA’s contact with mucosa may be limited. Lidocaine gel and paste can also be directly applied to the anterior/posterior tongue with an application device such as a tongue depressor. Moreover, the VL blade can be coated with lidocaine ointment to allow further application of TLA and to test the coverage area and evaluate the patient’s comfort and acceptability of the instrumentation.

There are also mucosal atomization devices available that can be connected directly to a lidocaine solution syringe. It is imperative to ensure the device is secured to the syringe. Dislodging the device from the syringe when spraying rarely occurs; however, if this does happen, the device could be lost inside the patient. The malleable atomizer device, if fashioned into a “curve” that replicates the VL blade, can also be used to spray the cords directly during VL.

The goal is to reduce coughing and reduce the risk for spasm when the trachea is intubated. Use of 4% “nebulized” lidocaine has also been described, typically for elective awake intubations, not in the emergency setting, and will not be described here. The time commitment is inappropriate in most cases and the patient’s inspiration/inhalation capabilities are limited. At Hartford Hospital, most providers will use 4% liquid lidocaine and an atomizer,¹⁷ as pictured in Figure 3.

In the emergency setting, patient preparation typically can be accomplished in two to three minutes and can be applied prior to or during BVM preoxygenation. Moreover, if continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) is in place, lifting the bottom or side of the in situ mask allows the operator to apply the TLA.

Review of 3 Cases

Here, three difficult NORAM cases from the Hartford Hospital database are presented.

Case 1

An 81-year-old man (5’9,” 145 kg) with a past medical history of diabetes, hypertension, OSA (obstructive sleep apnea), COPD (chronic obstructive pulmonary disease) and new-onset acute kidney injury (creatinine 2.2, normally 0.9) presented with fever, elevated white blood cell count, dysphagia and significant unilateral facial swelling (cheek, mandible, neck) that had been increasing over the last 30 days but more rapidly over the past three days. His medical team was concerned about his leukocytosis (56K), suggestive of lymphoma with secondary facial infection and edema.

He was admitted to the medical ICU for airway concerns, secretion control issues, altered voice, mild inspiratory stridor and shortness of breath.

The anesthesia STAT team was called to evaluate his airway stability due to his rapidly changing status and the need for radiographic imaging. On exam, he had limited cervical range of motion, a foreshortened thyromental distance (3 cm), a Mallampati score of IV, and limited mouth opening (about 1.5 fingerbreadths). He was edentulous. Secretion control was marginal and facial edema was significant. The anesthesia team decided to pursue an awake FFB approach given the clinical circumstances. Following his examination, they informed him that they would proceed with mild sedation and airway topicalization.

They summoned the surgical airway team (difficult airway response team, DART) to arrive prior to intubation to formulate a game plan at the bedside. The staff optimized elevation of the ICU bed to 65 degrees, and a full explanation was provided to the patient. The nursing staff were positioned at each side of the patient to provide physical and emotional support. Incremental IV midazolam was administered (total=1.5 mg). Oral and pharyngeal suctioning were performed with a 14 Fr soft suction catheter. Nasal cannula oxygen was administered at 6 L per minute. Oxymetazoline was applied to both nostrils in the event that a nasal route of intubation was needed should oral intubation fail. The oral cavity was anesthetized with 4% oral lidocaine (3 mL) for 20 to 30 seconds by swish, gargle and swallow (patient was cooperative). A mucosal atomization device was used to spray the orohypopharynx with 4 mL of 4% lidocaine twice. After several minutes, a “large” Williams airway (coated with 5% lidocaine ointment) was placed orally and well tolerated.

Allowing time to pass to provide maximal topicalization, a soft 14 Fr catheter was passed orally to remove any residual secretions. The CA-2 resident with moderate FFB experience (25 cases) but limited awake/aware cases (two previously) was positioned in front of the patient, performed a surveillance bronchoscopy (viewed on video screen for entire team to observe) and noted marked unilateral swelling of the entire orohypopharyngeal-supraglottic area, but with only mild glottic deviation and swelling. The bronchoscope was removed and a 7.0 Evac ETT was placed on the scope. Formal instrumentation of the airway then commenced. The FFB was gently advanced laterally to minimize trauma to the deviated tissues and was well tolerated.

Once the FFB tip was supraglottic, 3 mL of 4% lidocaine was delivered via the FFB port to anesthetize the glottis and subglottic region. This was met with minimal coughing. Advancement of the scope through the glottic opening was successful, as was ETT advancement. Vital signs remained stable and actually improved (BP, 155/88 to 133/76 mm Hg; HR, 112 to 83 beats per minute). Endotracheal intubation was successful, the tube was secured and the ICU staff began an IV sedation regimen. The surgical team was thanked and dismissed. The patient was labeled a “Difficult Airway” with an accompanying detailed story to recount his preparation and intubation.

Case 2

Anesthesia STAT was called to the medical ICU for a 46-year-old man (5’6,” 76 kg), just admitted, with a past medical history of hypertension, a current smoker, COPD, diabetes with fever, dysphagia, mild inspiratory stridor and a pronounced bilateral cervical lobular lymphadenopathy with mass effect easily visualized from across the room. The patient had been directly admitted from the otolaryngology office after their nasopharyngoscopy (MP-4) revealed a moderate-sized peritonsillar tumor mass extending down to the pyriform sinus, a normal-appearing glottis with unilateral vocal cord paresis, and excessive secretion burden.

Initial plans were to rehydrate the patient due to poor oral intake, start antibiotics for a suspected aspiration pneumonia, and obtain CT imaging. Unfortunately, he appeared worse than previously described and displayed tachypnea, room air desaturation and secretion control issues. Anesthesia notified the otolaryngology call team to the bedside along with the surgical airway team (DART). They prepared the patient for awake FFB.

Following a detailed explanation of the life-threatening nature of the situation and the reasoning to secure the airway in an awake manner, the patient underwent gentle suctioning followed by application of topical anesthesia (lidocaine 4%). In the upright position, two attempts to maneuver the fiberoptic bronchoscope to the glottis via a Williams airway failed due to redundant and edematous tissue obscuring advancement. The patient was tolerating the procedure well without any sedation. Due to the need to lift the pharyngeal tissue to hopefully expose the glottis, the head of the bed was lowered to 45 degrees and gentle placement of the VL (GlideScope) offered the ability to suction secretions and reveal a grade IIa glottic view.

The styleted ETT was carefully but easily advanced into the trachea. The patient then received sedation and analgesic agents for comfort. The patient was labeled a “Difficult Airway” with a detailed description of his airway anatomy and the management schema.

Case 3

Anesthesia STAT was called for hypoxic respiratory failure in a 64-year-old man (5’8,” kg) with a past medical history of hypertension, diabetes mellitus and OSA. He had suffered a traumatic head injury and aspiration pneumonia. He was known to have difficult airway management encounters in the elective OR setting. His records were reviewed. The DART team was summoned electively to the bedside for a management/strategy discussion. He was ramped, high-flow nasal oxygen was applied, and he was topicalized with local anesthesia and incrementally administered IV midazolam (total, 2 mg). VL, although well tolerated, offered a poor view (grade IV) by both the senior resident and attending staff. As the patient was cooperative and tolerant of these attempts, a bronchoscope was loaded with an ETT. While the resident performed VL, the attending maneuvered the flexible fiberoptic bronchoscope around the redundant pharyngeal tissue and traversed the glottic opening, leading to successful endotracheal intubation. Hemodynamics were stable and the patient then received a sedative–analgesia regimen by the ICU staff post-intubation. The patient had previously been labeled as a “Difficult Airway” but this was updated to reflect the details of this encounter.

The Anesthesia Airway Team

The Hartford Hospital NORAM database (1990-2023) has nearly 28,500 emergent intubation encounters, of which 2,600 are cardiac arrest–related intubations. The anesthesia airway team typically consists of an anesthesia attending, alone or with one to three anesthesia residents and/or CRNAs or additional attending staff. The nursing and RT staff deliver an airway tackle box to the bedside (with conventional/standard intubation equipment). The anesthesia team transports an airway suitcase (ETT, scopes, bougies, primary and secondary SGA devices in a variety of sizes and styles, and a surgical “cric” set). The team also travels with the combined VL/FFB tower to each location. All ICU and specialty areas are equipped with their own tower. The use of FFB and VL encompasses both elective and rescue deployments. Both methods will be detailed below.

Flexible Fiberoptic Bronchoscopy

Documented FFB usage accounted for 1,529 cases. Of these, 556 encounters involved FFB-assisted intubation via an SGA (LMA or intubating LMA Fastrach; Teleflex) and FFB deployment for airway rescue (Plans B, C or D) in 387 patients. The remaining 571 FFB cases consisted of elective primary use for securing the airway following TLA preparation with or without TLAS, or induction with a sedative-hypnotic (propofol, midazolam, etomidate, ketamine) with or without muscle relaxation (NMB) (Table 1).

This data review was retrospective in nature via chart analysis (days to weeks post-intubation). The overall rate of intubation success was high for elective FFB deployment. All FFB cases were performed by an attending staff member (49%) or a supervised anesthesia resident (51%). VL rescue (Plan B) or combining VL and FFB to complement the visibility from each technology plus the tissue lifting capabilities of VL were the most commonly employed rescue strategies. The overall success rate for intubation with FFB as the primary technique was high (Table 2).

The first-pass success rate was comparable among the various patient preparation techniques used for FFB cases (Table 3) yet considerably higher than the overall NORAM database rate of 67% (conventional DL with or without bougie or VL). There was a significant reduction in multiple attempts with FFB overall (Table 3).

Additionally, complications that are typically associated with multiple attempts (bradycardia, dysrhythmia, esophageal intubation, regurgitation and the need for a surgical airway), were considerably reduced in all FFB groups (Table 4). There was only one documented esophageal intubation in the FFB group versus 6.2% in the overall NORAM collection. Although very uncommon overall, there were no elective FFB cases that required a surgical airway “cric.” The incidence of desaturation during the intervention was significantly lower in FFB patients prepared with TLA with or without sedation (Table 5). The vast majority of these patients had ongoing nasal cannula oxygen delivery during the intubation procedure.

The incidence of post-intubation cardiac arrest in the entire elective FFB group was zero. Conversely, the overall database showed a 2.8% incidence. Post-intubation hypotension that required vasoactive agents to support the patient’s hemodynamics was much lower in those prepared with TLA or TLAS (TLA, 4.8%; TLAS, 3.4%) versus those who underwent GA induction with or without NMB (23%), compared with the overall database of 33%.

The decision to incorporate FFB as the primary method in NORAM was at the discretion of the anesthesia team, but generally it was based on known or suspected difficult airway characteristics. The various factors that raised the concerns for a potential/known difficult airway are outlined in Figure 4. A high Mallampati score (IV) was prolific, as was Mallampati III (TLA, 21%; TLAS, 31%). Limited or no cervical range of motion, either by the presence of a hard cervical collar or noted on a brief airway examination at bedside, was the most common difficult airway trait noted in the FFB group.

A significant number of elective FFB patients were found to be suffering from head/neck swelling due to a variety of clinical grounds (anaphylaxis, angioedema, infection, mass effect, trauma, hematoma-based, tumor burden, etc.). These findings likely swayed the airway team toward an awake FFB option.

A limited thyromental space was also a frequent difficult airway trait (Figure 4). Preexisting head/neck swelling, infection, edema or mass effect was a common factor that likely influenced the anesthesia team to pursue TLA/TLAS preparation with FFB. Two out of every five FFB encounters had an elevated BMI (morbidly obese) as an additional difficult airway factor.

Trismus (<2 fingerbreadths opening, or a “small mouth opening”) was a less common yet important difficult airway trait contributing to the team’s management schema, especially when considering that a small mouth opening or trismus would likely favor FFB over VL utilization. The airway team chose an awake nasal FFB approach in five patients due to limited mouth opening.

Video-Assisted Laryngoscopy

VL (specifically, GlideScope) was brought into service at our institution in 2006. Other VL technology available for use by staff over the years included the Bullard & Upsher scopes, Airtraq (Prodol Meditec), Shikani (Clarus) and the McGrath (Medtronic) scopes. Since 2006, the GlideScope has been used in 9,764 NORAM encounters (elective-7,990; rescue-1,774). Patients prepared with TLA/TLAS accounted for 1,066 VL encounters. Elective VL encounters using TLA/TLAS were documented in 860 patients (rescue VL use with TLA/TLAS, 206 patient encounters).

A portion of this group likely received TLA/TLAS preparation due to the anesthesia team’s concern with their current or anticipated hemodynamic instability based on their vital signs at the time of the airway intervention (marginal BP, hypotension, tachycardia, dysrhythmias) or their known/suspected underlying reason for the airway intervention (cardiopulmonary dysfunction, myocardial infarction [MI], pulmonary embolism, tamponade, post-arrest with return of spontaneous circulation [ROSC], sepsis, shock). These patients were removed from the TLA/TLAS group because they lacked difficult airway traits, as mentioned previously (n=229), leaving 631 VL patient encounters with known/suspected difficult airway concerns.

The overall intubation success with VL and TLA preparation with or without light sedation was impressive (94%-95%), akin to the TLA–TLAS–FFB groups. Fourteen cases, seven each, had successful intubations with the primary VL when combined with FFB to assist with ET maneuverability into the trachea. Hence, overall VL success rate rose to 95.8% (TLA–VL) and 98% (TLAS–VL) when augmenting VL with FFB assistance. Overall, VL rescue (Plan B) for FFB difficulty or combining VL and FFB to complement the visibility offering of each technology, plus tissue-lifting capabilities by incorporating VL, were the most commonly employed rescue strategies in both the VL and FFB groups.

A high Mallampati score (IV) was quite common (63%, TLA; 54%, TLAS), as was Mallampati III (21%, TLA; 31%, TLAS). Limited or no cervical range of motion, either by the presence of a hard cervical collar or noted on a brief airway examination at the bedside, was the most common difficult airway trait noted in the VL group (Figure 5). Preexisting head/neck swelling, infection, edema or mass effect, previously mentioned above, were less commonly factors to pursue TLA/TLAS–VL compared with FFB.

A limited thyromental space was also a frequent difficult airway trait. Over 60% of patients in each VL grouping had an elevated BMI (morbidly obese) as a difficult airway factor (Figure 5). The presence of an elevated BMI (>35) was more common in the VL (67%, TLA; 70%, TLAS) than FFB (˜40%) group. Additionally, trismus (<2 fingerbreadths opening or a “small mouth opening”) was a less common yet important difficult airway trait contributing to the team’s management schema. VL performance with trismus is often limited due to inability to place/manipulate the scope blade, a stylet/ETT or both.

As previously stated, the overall rate of intubation success was high for elective VL deployment in the TLA–TLAS group. A significant reduction in multiple attempts with VL, as there was with FFB, was evident. The rate of three or more VL attempts required was four times lower than in the overall database (4% vs.17%). As with FFB, complications that are typically associated with multiple attempts (bradycardia, dysrhythmia, esophageal intubation, regurgitation and the need for a surgical airway) were considerably reduced in the VL groups. The incidence of documented esophageal intubation was much lower (TLA, 2.1%; FFB TLAS, 0.8%) compared with the overall database (6.2%). The incidence of desaturation during the elective VL interventions was lower in those patients prepared with TLA with or without sedation compared with the overall NORAM group. The majority of TLA–TLAS VL cases underwent preoxygenation via BVM or had their in-line BiPAP/CPAP maintained until laryngoscopy.

Although very uncommon overall (0.7%), there was only one elective VL case that required a surgical airway “cric” for rescue. This case involved VL obtaining a marginal view and the inability to maneuver the ETT into the trachea. FFB combined with VL was unsuccessful, leading to placement of an SGA. FFB via the SGA failed due to extensive edema and secretions, thus leading to the decision to “cric” the patient. The SGA supported ongoing oxygenation and ventilation during the surgical intervention.

Similar to FFB, the incidence of post-intubation cardiac arrest in the entire elective TLA–TLAS VL group was zero (NORAM, 2.8%). Similar to FFB, post-intubation hypotension that required vasoactive agents to support the patient’s hemodynamics was much lower in those prepared with TLA–TLAS (TLA, 10.6%; TLAS, 10.7%), compared with the overall database of 30%, although higher than the topically prepared FFB group (about 4%).

Conclusion

In summary, emergent and urgent NORAM can be fraught with hemodynamic and airway-related complications. Being prepared to employ the correct primary and backup rescue tools and techniques for each emergency airway situation is critical to decreasing the risk for hemodynamic derangements and failed intubation attempts.

This data review suggests that the various hemodynamic perturbations and airway-related complications can be reduced using VL or FFB, with rapidly applied airway topicalization without supplemental nerve blocks (Table 6). Proper patient selection, preparation and careful explanation to the patient, if appropriate or possible, of airway topicalization can significantly reduce the need for associated sedative-hypnotics-anxiolytics and neuromuscular blockade during airway emergencies.

Airway topicalization and tailoring the intubation plan for the specific clinical scenario are critical for reducing the complication rate of NORAM. In our database, there were zero cases of cardiac arrest in the FFB and VL groups if topical local anesthesia preparation, with or without light sedation, was used, compared with a rate of cardiac arrest of 2.8% in the entire NORAM database. The incidence of post-intubation bradycardia, dysrhythmias and hypotension requiring vasoactive agent supplements/infusions was markedly reduced compared with the overall NORAM patients receiving non-TLA induction medications.

The TLA/TLAS techniques should be included in the armamentarium of all anesthesiologists to enhance their practice and provide potentially safer patient care, especially when confronted with suspected or known difficult airway characteristics. Though not a randomized controlled comparison of VL vs. FFB, this review suggests that both VL and FFB, when used as a primary method to secure the airway in NORAM patients under emergency circumstances, are highly successful. Moreover, the valuable combination of VL+FFB has the potential for a reliable rescue technique. Both VL and FBB appear to have similar success rates and complication profiles, and each outperforms standard induction-based intubation in the NORAM population.

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