Awake Tracheal Intubation
We recommend awake tracheal intubation under meticulous topical anesthesia, preferably by using a flexible bronchoscope (FB), as the safest approach to the management of a difficult airway situation when preparation time is of minor concern. In a large case series of patients requiring airway control for surgical interventions of deep neck infections, Ovassapian and co-workers (19) demonstrated that awake flexible-bronchoscopy assisted (FBA) tracheal intubation performed by experienced operators together with adequate preparations and the help of a qualified assistant can be highly successful.
FBA orotracheal intubation is feasible in many of these patients but may fail particularly in those with largely restricted pharyngeal space; in these situations, orotracheal intubation using a laryngeal mask airway as conduit under guidance by a FB or FBA nasotracheal intubation may be more successful. In addition to failed identification of anatomic structures, the tracheal tube (TT) may occasionally not enter the trachea when the FB is positioned inside the trachea due to impingement of the TT on the arytenoids or the interarytenoid area and the flexibility of the FB (3). On rare occasions, the FB may completely obstruct the airway when passing the laryngeal aperture.
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