Awake Videolaryngoscopy: Effective and Safe in Anticipated Difficult Intubations

TOPLINE:

Across awake tracheal intubations using videolaryngoscopy for suspected difficult airways, the overall success rate was high. Overall or first-attempt success rates did not differ between non-channeled and channeled devices.

METHODOLOGY:

• Researchers conducted a prospective observational cohort study capturing all awake tracheal intubations using videolaryngoscopy over 3 years in three hospitals in Spain.
• They included 298 adult patients (mean age, 64 years; 68% men) requiring tracheal intubation, for whom anesthesiologists chose awake videolaryngoscopy for anticipated difficult airways in the operating rooms or ICU, with the choice guided by predictors of difficult intubation, the need to maintain the neutral position of the cervical spine, or a Simplified Airway Risk Index score of 4 or higher.
• The procedural approach included standard monitoring, supplemental oxygen administration targeting an oxygen saturation greater than 90%, clinician-directed sedation with a recommended Ramsay Sedation Scale score of 2, and topical-infiltrative lidocaine administration at a maximum total dose of 9 mg/kg.
• The devices used were channeled Airtraq, which was used in 19.8% of cases, and non-channeled C-MAC D-Blade or McGrath X3 scopes, which were used in 80.2% of cases. Success was confirmed via continuous waveform capnography and bilateral chest auscultation, with attempts defined by each new insertion of the videolaryngoscope, tube, or guide.
• The primary outcome was the overall success rate of the awake tracheal intubations using videolaryngoscopy, and the secondary outcomes were the rate of first-attempt success, operator-rated difficulty, patient satisfaction, and complications.

TAKEAWAY:

• Overall, the success rate of awake tracheal intubation using videolaryngoscopy was 95%, with no differences found between non-channeled and channeled videolaryngoscopes for overall success (95% vs 94.5%).
• First-attempt success occurred in 68.1%, with no significant difference between the devices. Awake tracheal intubation failed in 15 patients, with the failure rate of 5% with non-channeled videolaryngoscopy and 5.1% with channeled videolaryngoscopy.
• Operator-reported difficulty was rated none or mild in 82.6% of cases, with no significant difference in perceived difficulty between the two types of videolaryngoscopes.
• The most frequent complication associated with the use of videolaryngoscopy was secretions obscuring the glottic view (8.1%).

IN PRACTICE:

“Awake tracheal intubation using videolaryngoscopy is an effective and safe technique for patients with anticipated difficult airways. Both channeled and non-channeled VLs [videolaryngoscopes] achieved high overall success rates and a low incidence of major complications, suggesting that device selection should be tailored to patient characteristics and operator experience. The favorable patient tolerance and low perceived procedural difficulty further support the role of VL as a valuable tool in advanced airway management,” the researchers wrote.