Awake VDL Intubation With Dexmedetomidine, a Case Series (DexAwake)
Condition: Awake Intubation
Study type: Observational

Summary: 
      Early after the videolaryngoscope'(VDL) introduction in clinical practice, the awake
      videolaryngoscopic (A-VDL) intubation took place with and instead of the awake
      video-bronchoscopic (A- VBS) intubation. The awake intubation is a safe profile technique
      that was underused since the only instrumentation available was the fiberoptic bronchoscope
      (FOB) or more recently the video-bronchoscope (VBS). With the VDL diffusion, the awake
      intubation option has eventually turned into a more utilized procedure, with the potential to
      become a daily procedure. This was also due to dexmedetomidine (DEX) introduction in The
      Operating Room pharmacopeia. Several steps must be standardized in order to homogeneously
      apply an awake intubation protocol. A department protocol is recommended (awake intubation
      guidelines) but a low threshold for enrollment can be used to shorten and standardize the
      execution times. This study aims to create a protocol and measure the outcomes.
    

Detailed description: 
      Early after the videolaryngoscope'(VDL) introduction in clinical practice, the awake
      videolaryngoscopic (A-VDL) intubation took place with and instead of the awake
      video-bronchoscopic (A- VBS) intubation. The awake intubation is a safe profile technique
      that was underused since the only instrumentation available was the fiberoptic bronchoscope
      (FOB) or more recently the video-bronchoscope (VBS). With the VDL diffusion, the awake
      intubation option has eventually turned into a more utilized procedure, with the potential to
      become a daily procedure. This was also due to dexmedetomidine (DEX) introduction in The
      Operating Room pharmacopeia.

      The emergency use of rescue techniques after failed intubation throws the operator into the
      rare, but unwanted emergency "Front of Neck Access" (FONA) scenario, while a failed awake
      intubation brings (carry, get) the operator into the "patient not intubated but safely and
      spontaneously breathing" scenario, moving away from the events of hypoxic complications and
      death.

      Several steps must be standardized in order to homogeneously apply an awake intubation
      protocol. First, the patients need to be clinically evaluated for difficult intubation
      predictors. Most of the articles about prediction only investigated the relationship between
      difficult intubation' predictors and direct laryngoscopy and they showed poor to moderate
      sensitivity and specificity (Toshiga Shiga, Vannucci) but, moving on VDL' world this
      relationship has changed as showed by Cortellazzi et al with an AUC for El Ganzouri Risk
      Index improving from 0.74 to 0.9 using DL and Glidescope respectively. In addition to these
      considerations, all the most recent Airway Management Guidelines has confirmed as unmissable
      the clinical evaluation of anthropometric and clinical DI predictors. (DAS) Along with
      measuring all the EGRI parameters, it is pivotal to examine any abnormality in the head,
      pharyngo-laryngeal, neck, spine, and abdominal anatomy. Previous neck irradiation, mass
      lesions, neck circumference, super-obesity, severe cervico-dorsal kyphosis, or past
      pharyngo-laryngeal surgery have to be considered and may not alter the EGRI score that is,
      incidentally, made -as the other predictors -for apparently normal patients (Shiga).

      A department protocol is recommended (awake intubation guidelines) but a low threshold for
      enrollment can be used to shorten and standardize the execution times.

      We retrospectively evaluated 24 patients (from January 2019 to June 2021). For descriptive
      purposes, there are five procedural "Times": T0, T1, T2, T3, T4 and T5. T 0 is the start of
      the dexmedetomidine charge dose and local oral-pharyngeal anesthetic. In T1, the GAG reflex
      check is performed. In T2 fentanyl or ketamine is delivered. In T3 the local anesthetic is
      nebulized on vocal cord and trachea, under videolaryngoscopic view. T4 is the tube passage
      through the vocal cords. T5 is the EtCo2 curve assessment. At the end outcomes were measured.
    

Intervention name(s): Awake intubation
Intervention type(s): Other
Intervention description(s): Awake videolaryngoscopic intubation with dexmedetomidine for sedation
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Primary care clinic