Awake fiberoptic intubation AFOI in anticipated difficult airway management: dexmedetomidine versus propofol–fentanyl combination

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Abstract

Background

In patients with anticipated difficult airway, awake fiberoptic intubation (AFOI) is highly indicated. Preparation of the patient for optimal intubating conditions requires adequate anxiolysis while maintaining patient safety with respect to a patent airway and adequate ventilation. The present study compared dexmedetomidine (dex) with propofol–fentanyl (prop–fent) combination in terms of intubation condition and patient safety.

Methods

Forty patients were divided randomly into two groups: a prop–fent group, which received continuous infusions of propofol 30 μg/kg/min and fentanyl 0.5 μg/kg/h, and a dex group, which received dex. 1 µg/kg as a loading dose for 10 min, followed by a continuous infusion of 0.7 µg/kg/h. The parameters analyzed included the percentage of patients requiring rescue midazolam, total dose of rescue midazolam, anesthesiologist’s assessment of intubation condition, and patients’ and anesthesiologists’ satisfaction. Other parameters included hemodynamic changes, hypoxia, and state entropy at intubation.

Results

Fewer dex-treated patients compared with prop–fent-treated patients required rescue midazolam to achieve/maintain Ramsay Sedation Scale level 2 (20 vs. 60%; P<0.001), and the supplemental midazolam dose was lower (0.6±0.85 vs. 1±1.05 mg; P<0.001). In terms of adverse hemodynamic effects, more frequent hypotension was observed in the dex group compared with the prop–fent group (20 vs. 10%; P<0.05). Hypertension was reported only in the prop–fent group (15 vs. 0%; P<0.05). Tachycardia was more frequent in the prop–fent group compared with the dex group (10 vs. 5%; P<0.05). Bradycardia was more common in the dex group compared with the prop–fent group (20 vs. 15%; P>0.05). Hypoxia did not occur in any patient in the dex group compared with one only patient in the prop–fent group (0 vs. 5%; P>0.05). Intubation scores were better in the dex group compared with the prop–fent group (P value <0.05) in terms of vocal cord movement. At intubation, it was found that patients in the dex group had lower levels of state entropy than patients in the prop–fent group (67.2±6.3 vs. 87.1±2.7; P value <0.05). Anesthetists rated their satisfaction with the technique as excellent in 90% of patients treated with dex compared with 70% of patients treated with prop–fent (P<0.05). In terms of patients’ satisfaction, it was found that 50% of patients in the dex group rated their satisfaction as excellent compared with 15% of patients in the prop–fent group (P<0.05). Patients’ recall of topical anesthesia, endoscopy, and intubation were generally higher in the prop–fent group (30, 5, and 5%, respectively) compared with the dex group (5, 0, and 0%, respectively) (P<0.05, P>0.05, and P>0.05, respectively).

Conclusion

Both the dex and the prop–fent regimes provided upper airway patency comparable to that of awake patients, satisfactory intubating conditions, and patient and anesthetist satisfaction in the majority of patients undergoing awake fiberoptic intubation. Dex appeared to offer better patient satisfaction, less patient recall of procedure, better anesthetist satisfaction, and a reduced hemodynamic response to intubation.

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