Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Aug 16, 2021; 9(23): 6705-6716
Published online Aug 16, 2021. doi: 10.12998/wjcc.v9.i23.6705
Awake fiberoptic intubation and use of bronchial blockers in ankylosing spondylitis patients
Shao-Zhong Yang, Shan-Shan Huang, Wen-Bo Yi, Wei-Wei Lv, Liang Li, Feng Qi
Shao-Zhong Yang, Shan-Shan Huang, Wen-Bo Yi, Liang Li, Feng Qi, Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
Wei-Wei Lv, Department of Radiology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
Author contributions: Yang SZ, Yi WB, and Qi F performed the research; Huang SS helped to analyze the data; Li L helped to collect the data; Lv WW provided imaging data; Yang SZ and Lv WW analyzed the data and wrote the manuscript; Qi F conducted the study and revised the manuscript; all authors have read and approved the final manuscript.
Supported by National Natural Science Foundation of China, No. 81672250; and Special Fund for Resident Training in Qilu Hospital of Shandong University, No. ZPZX2019A08.
Institutional review board statement: The study was approved by the Ethics Committee of the Qilu Hospital of Shandong University (No. KYLL-202008-033).
Informed consent statement: Written informed consent from the patients in this study was waived.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
Data sharing statement: No data sharing.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Feng Qi, MD, Chief Physician, Department of Anesthesiology, Qilu Hospital of Shandong University, No. 107 Wenhua West Road, Jinan 250012, Shandong Province, China. qifeng66321@sina.com
Received: January 7, 2021
Peer-review started: January 7, 2021
First decision: February 12, 2021
Revised: February 21, 2021
Accepted: April 20, 2021
Article in press: April 20, 2021
Published online: August 16, 2021
Processing time: 210 Days and 6.3 Hours
ARTICLE HIGHLIGHTS
Research background

Severe kyphosis is common in late stage of ankylosing spondylitis (AS), and tracheal intubation, especially one-lung ventilation, is particularly difficult. Such patients are rare, and have a predictable difficult airway. Awake fiberoptic intubation is the safest choice. Compared with double lumen bronchial catheter, the use of bronchial blocker for one-lung ventilation is particularly suitable for such patients. It is a great challenge for anesthesiologists to choose sedative drugs and methods to complete awake fiberoptic intubation while ensuring oxygenation.

Research motivation

Twelve cases of AS with spinal deformity were analyzed retrospectively to summarize the drug selection, appropriate dose, and patient tolerance of awake fiberoptic intubation, so as to provide guidance for clinical predictable awake fiberoptic intubation and one-lung ventilation in difficult airway.

Research objectives

To summarize the drug selection, appropriate dose, and patient tolerance of awake fiberoptic intubation.

Research methods

The electronic case records were used to collect the general information of patients. Preoperative airway assessment of difficult airway (including Wilson's score, Mallampati classification, thermomental distance, interval gap, neck mobility, etc.) was performed. Appropriate doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl and midazolam were given before intubation, and the nasal cavity was treated with a lidocaine and ephedrine cotton swab. The preparation time before tracheal intubation, intubation time, facial expression score, airway responsiveness score when fiberoptic bronchoscope was introduced, and airway responsiveness score when tracheal intubation entered the nostril were recorded. Lung collapse and surgical field score was recorded. Blood pressure and heart rate were recorded at different time points. The patients were followed for nasal bleeding, sore throat, hoarseness, dysphagia, etc.

Research results

Among the 12 patients, 11 were male and 1 was female; the history of AS was 20.4 ± 9.6 years, the Willson's scores were 5 or above, Mallampati tests were grade III or IV, the inter-incisor distance was 2.9 ± 0.3 cm, and the thyromental distance was 4.8 ± 0.7 cm. The preparation time before intubation was 20.4 ± 3.4 min, and the intubation time was 2.6 ± 0.4 min. The facial grimace score was 1.7 ± 0.7, the airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score were 1.2 ± 0.4. The SBP, DBP, and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). While the values at T1 were not significantly different from those at T2-T4 (P > 0.05), they were significantly different from those at T5 (P< 0.05). Seven patients had minor epistaxis during endotracheal intubation, two were followed 24 h after surgery with mild sore throat, and two had hoarseness without dysphagia.

Research conclusions

Ankylose spondylitis patients with severe cervical and thoracic kyphosis should be intubated by fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Before intubation, proper dosage of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, can provide satisfactory tracheal intubation conditions while maintaining the comfort and safety of patients. Bronchial blocker is safe and effective for one-lung ventilation in such patients during thoracotomy.

Research perspectives

The Tampa bronchial blocker used in adults can pass through the endotracheal tube with the minimum inner diameter of 7.0, which leads to a larger inner diameter of the endotracheal tube selected for nasal intubation and higher incidence of epistaxis. The comfort of individual patients during intubation is slightly poor, so it is necessary to further explore the individualized use of sedative drugs. How to choose a more reasonable ventilation mode for patients with special difficult airway needs to be further explored.