Retrospective Study Open Access
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, 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
ORCID number: Shao-Zhong Yang (0000-0003-4958-1232); Shan-Shan Huang (0000-0001-5587-9989); Wen-Bo Yi (0000-0002-7219-1462); Wei-Wei Lv (0000-0001-9012-1436); Liang Li (0000-0002-9386-6086); Feng Qi (0000-0002-0272-493X).
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

Abstract
BACKGROUND

Patients with ankylosing spondylitis (AS) combined with severe cervical fusion deformity have difficult airways. Awake fiberoptic intubation is the standard treatment for such patients. Alleviating anxiety and discomfort during intubation while maintaining airway patency and adequate ventilation is a major challenge for anesthesiologists. Bronchial blockers (BBs) have significant advantages over double-lumen tubes in these patients requiring one-lung ventilation.

AIM

To evaluate effective drugs and their optimal dosage for awake fiberoptic nasotracheal intubation in patients with AS and to assess the pulmonary isolation effect of one-lung ventilation with a BB.

METHODS

We studied 12 AS patients (11 men and one woman) with lung or esophageal cancer who underwent thoracotomy with a BB. Preoperative airway evaluation found that all patients had a difficult airway. All patients received an intramuscular injection of penehyclidine hydrochloride (0.01 mg/kg) before anesthesia. In the operating room, dexmedetomidine(0.5 μg/kg) was infused intravenously for 10 min, with 2% lidocaine for airway surface anesthesia, and a 3% ephedrine cotton swab was used to contract the nasal mucosa vessels. Before tracheal intubation, fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) were administered intravenously. Awake fiberoptic nasotracheal intubation was performed in the semi-reclining position. Intravenous anesthesia was administered immediately after successful intubation, and a BB was inserted laterally. The pre-intubation preparation time, intubation time, facial grimace score, airway responsiveness score during the fiberoptic introduction, time of end tracheal catheter entry into the nostril, and lung collapse and surgical field score were measured. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded while entering the operation room (T1), before intubation (T2), immediately after intubation (T3), 2 min after intubation (T4), and 10 min after intubation (T5). After surgery, all patients were followed for adverse reactions such as epistaxis, sore throat, hoarseness, and dysphagia.

RESULTS

All patients had a history of AS (20.4 ± 9.6 years). They had a Willson's score of 5 or above, grade III or IV Mallampati tests, an inter-incisor distance of 2.9 ± 0.3 cm, and a thyromental (T-M) distance of 4.8 ± 0.7 cm. The average pre-intubation preparation time was 20.4 ± 3.4 min, intubation time was 2.6 ± 0.4 min, facial grimace score was 1.7 ± 0.7, airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score was 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 a mild sore throat, and two had hoarseness without dysphagia.

CONCLUSION

Patients with AS combined with severe cervical and thoracic kyphosis should be intubated using fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Proper doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, administered prior to intubation, can provide satisfactory conditions for tracheal intubation while maintaining the comfort and safety of patients. BBs are safe and effective for one-lung ventilation in such patients during thoracotomy.

Key Words: Awake fiberoptic intubation, Bronchial blocker, Ankylosing spondylitis, Difficult airway, One-lung ventilation

Core Tip: To summarize the drugs and their optimal doses for awake fiberoptic nasotracheal intubation in patients with ankylosing spondylitis (AS), and to evaluate the pulmonary isolation effect of one-lung ventilation with bronchial blocker, 12 AS patients complicated with lung or esophageal cancer underwent thoracotomy with a bronchial blocker. The final conclusion is that AS patients with severe cervical and thoracic kyphosis should be intubated by fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Bronchial blocker is safe and effective for one-lung ventilation in such patients during thoracotomy.



INTRODUCTION

Ankylosing spondylitis (AS) is a type of autoimmune spondyloarthropathy characterized by chronic progressive exacerbation, with severe complications, such as hip fusion, spinal deformity, and spinal fracture, often occurring in the advanced stage. Severe kyphosis of the cervical spine and thoracic vertebrae often leads to cardiovascular and respiratory complications[1]. Patients at a later stage often require surgery to improve the inability to walk and quality of life, or if they have other diseases requiring surgical interventions. However, severe kyphosis can lead to difficulties in ventilation and intubation, posing a great challenge for anesthesiologists in perioperative management, especially that of the airway.

For adequate surgical site exposure and optimal visual field, thoracic surgery requires pulmonary isolation and one-lung ventilation. One-lung ventilation can be achieved using a double-lumen tube (DLT) or bronchial blocker (BB). Traditionally, a DLT is more commonly used, although the hardness and thick diameter of the pipe increase the risk of tracheal and bronchial damage[2]. However, DLT is being replaced in an increasing number of thoracic surgeries by BB, which has the advantage of allowing a simple, rapid, and less traumatic procedure with no need to change the tube, and can be used for all kinds of airways, especially in difficult ones[3].

Patients with severe kyphosis often have reduced cervical vertebra and atlantooccipital joint movement, difficulty opening the mouth, and cervical and thoracic vertebrae in fixed flexion positions, making tracheal intubation difficult. During airway management, the excessive extension may lead to cervical spine injury and fracture. Therefore, awake fiberoptic intubation is the safest option in these cases. For AS patients undergoing thoracic surgery, there have been few reports on one-lung ventilation with a BB after awake fiberoptic nasotracheal intubation. This study retrospectively analyzed the clinical data on 12 AS patients with spinal deformities who underwent awake fiberoptic nasotracheal intubation and one-lung ventilation with a BB. We have also summarized the airway management methods used for these patients.

MATERIALS AND METHODS
Clinical data

Twelve patients with AS complicated with lung or esophageal cancer who underwent thoracic surgery under lung isolation with a BB at the Qilu Hospital of the Shandong University from January 2015 to August 2020 were included.

The inclusion criteria were: (1) Diagnosis of lung or esophageal cancer requiring surgical treatment; (2) Clear diagnosis of AS based on the American Society of Rheumatology as New York standard, which was revised in 1984[4]; and (3) Provided a signed agreement for the method of intubation and anesthesia. Patients (1) Excluded from other lung isolation methods or intubation failure; (2) With a history of drug abuse and mental illness; and (3) With masses inside the nasal cavity (e.g., polyps) and deviated nasal septum were excluded from the study.

The mean age of the 12 patients (11 men and one woman) was 57 (range, 41-68) years. They weighed 45-81 kg and had a body mass index (BMI) of 16.6-28.0. All the patients had a kyphotic deformity of the cervical and thoracic vertebrae and restricted mouth opening. They had physical status II or III as per the American Society of Anesthesiologists, with grade III or IV Mallampati airway, and Willson comprehensive score ≥ 5 points[5], but no cardiovascular or neuropsychiatric diseases.

Anesthesia method

Preoperative airway evaluation and anesthesia were performed in all patients by the same anesthesiologist. The preoperative airway evaluation included the Mallampati test and measurement of the inter-incisor distance, thyromental distance, neck mobility, and Willson score (Figures 1 and 2). Following the airway assessment, 12 cases with difficult airways were identified according to the practice guidelines for the management of difficult airways established by the American Society of Anesthesiologists[6] and the Chinese Society of Anesthesiology. Fiberoptic nasotracheal intubation was performed under conscious sedation and topical anesthesia. All the patients fasted for 8 h and did not drink anything for 4 h before surgery. Before anesthesia, the patients received an intramuscular injection of 0.01 mg/kg penehyclidine hydrochloride. Peripheral venous access was established after entering the operation room, and blood pressure (BP), heart rate (HR), ECG, and oxygen saturation of blood were monitored. Oxygen was administered at 6 L/min via the mask, and a radial artery cannula was placed to monitor arterial BP, with an intravenous infusion of dexmedetomidine (0.5 μg/kg) for 10 min. Before surgery, nasal polyps and nasal septal deviations were excluded. The nasal cavity was selected to be patchier, and the nasal mucosal vessels were contracted using a 3% ephedrine hydrochloride cotton swab. A single-lumen endotracheal tube (ETT) 7.0-7.5 mm in diameter was selected, and the front surface was lubricated with sterile lidocaine cream. Due to the severe cervical and thoracic kyphosis, patients were intubated in the high semi-recumbent position with head and neck pads (Figures 3 and 4). Intravenous fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) were administered before endotracheal intubation, requiring a Ramsay sedation score of 2-4 to avoid excessive sedation (Table 1).

Figure 1
Figure 1 Preoperative airway assessments.
Figure 2
Figure 2 Computed tomography images showing the disappearance of normal curvature of the cervical spine, bamboo-like changes, and severe kyphosis of the thoracic vertebra.
Figure 3
Figure 3 Spinal deformity that caused a patient to be unable to lie flat.
Figure 4
Figure 4 Preparation before awake fiberoptic nasotracheal intubation.
Table 1 Drugs used for awake tracheal intubation in the participants.
Drug
Usage and dosage
Penehyclidine hydrochloride injection0.01 mg/kg, intramuscular injection 30 min before anesthesia
Dexmedetomidine Intravenous infusion of 0.5 μg/kg for 10 min
Ephedrine hydrochloride3%, nasal drops
2% lidocaine3 mL for topical anesthesia of nasal mucosa and nasopharynx; 2 mL for thyrocricocentesis
Compound lidocaine creamLubrication on forepart of endotracheal tube and local anesthesia
Fentanyl1 μg/kg, analgesia, sedation, and inhibition of airway reflex
Midazolam0.02 mg/kg, sedation and anticonvulsant

A fiberoptic bronchoscope (FOB) with a tip diameter of 3.1 mm was selected and operated by an anesthesiologist proficient in FOB intubation. The FOB was pushed slowly through the nasal cavity until the forepart reached the mid-trachea. The ETT was gently pushed along the trunk until its front end reached 3-4 cm from the carina. After successful intubation, the FOB was quickly removed.

During the operation, the patient's reactions were monitored. If the patients had no obvious symptoms such as nausea, cough, or painful facial grimace, the disappearance of vocal cord activity was observed under the FOB to indicate effective airway surface anesthesia. When the FOB and ETT entered the nostril, the facial grimace was scored, and airway responsiveness was scored when entering the trachea[7]. After successful tracheal intubation, intravenous induction was immediately performed. The patient was placed laterally with a Tappa 9FR BB within the ETT and FOB down for bronchial obstruction. After adjusting the insertion depth, the upper edge of the blocker cuff was placed below the bronchus carina. Pulmonary collapse and surgical exposure were evaluated and recorded intraoperatively, according to the method of Campos[8].

Observation indexes

Perioperative clinical data, collected from the electronic medical records, included age, sex, BMI, history of AS, imaging findings, preoperative airway assessment, intubation time, patient reaction during intubation (facial grimace score, airway responsiveness, and comfort), pulmonary collapse and surgical exposure, and postoperative epistaxis, sore throat, hoarseness, dysphagia, and other adverse reactions.

Statistical analysis

Statistical analyses were performed using SPSS 24.0 (SPSS Inc., Chicago, IL, USA). The data are expressed as the mean ± SD, using ANOVA and paired t-test. Statistical significance was set at P < 0.05.

RESULTS

Table 2 summarizes the clinical data for the 12 patients. The patients had an average history of AS for 20.4 ± 9.6 years. They had a Willson's score of 5 or above, grade III or IV Mallampati tests, an inter-incisor distance of 2.9 ± 0.3 cm, and a thyromental (T-M) distance of 4.8 ± 0.7 cm (Table 3). All intubations were successful. The pre-intubation preparation time was 20.4 ± 3.4 min (including radial artery catheterization, sedation, nasopharyngeal topical anesthesia, nasal preparation, and thyrocricocentesis), and the intubation time was 2.6 ± 0.4 min (from the time of the entry of the FOB in the nose to the front end of the tracheal tube to the point 3-4 cm from the carina). The average facial grimace score was 1.7 ± 0.7, the airway responsiveness score was 1.1 ± 0.7 (Table 4), and the pulmonary collapse and surgical exposure score was 1.2 ± 0.4. T5 was the time point 10 min after intubation (after rapid intravenous drug induction). As shown in Table 5, systolic BP (SBP), diastolic BP (DBP), and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). The values at T1 were not significantly different from those at T2-T4 (P > 0.05) but were significantly different from those atT5 (P < 0.05). Seven patients had minor epistaxis during endotracheal intubation, two had a mild sore throat and were followed for 24 h after surgery, and two had hoarseness without dysphagia (Table 6).

Table 2 Demographic data of the patients.
Case
Gender
Age (yr)
Height (cm)
Weight (kg)
ASA physical status
Time since AS diagnosis (yr)
1Male6317770III15
2Male5916572III20
3Male5217168III13
4Male4117048III9
5Male5616251III16
6Male6816661III22
7Male6316859III40
8Male6115545III30
9Male5417360III24
10Male6016555III18
11Female5915547III31
12Male4317081III7
Table 3 Preoperative airway assessments.
Case
Willson's score
Mallampati classification
Thyromental distance (cm)
Interincisor gap (cm)
Neck mobility (º)
16III5.53.5< 90
25III4.53< 90
34III5.83.2< 90
45III63< 90
55III4.33< 90
66III3.82.5< 90
75IV42.4< 90
85IV53< 90
95III4.82.7< 90
105III4.52.5< 90
116IV4.22.6< 90
125III4.82.8< 90
Table 4 Evaluation during intubation.
Case
Preparation time before intubation
Intubation time (min)
Scores of facial grimaces
Airway reactivity score
1253.322
2182.511
322321
4272.710
5153.111
6192.621
7202.211
8231.922
9182.121
10212.610
11202.832
1217221
Table 5 Hemodynamic changes.

SBP/mmHg
DBP/mmHg
HR/min
Number of cases121212
T1136 ± 1879 ± 1287 ± 12
T2125 ± 1377 ± 778 ± 13
T3136 ± 1683 ± 892 ± 10
T4124 ± 1076 ± 678 ± 9
T5108 ± 1170 ± 767 ± 8
Table 6 Pulmonary collapse and surgical exposure, and postoperative adverse reactions.
Case
Pulmonary collapse and surgical exposure
Epistaxis
Sore throat
Hoarseness
Dysphagia
111000
210000
310000
411000
521000
610000
720000
811100
910010
1011000
1111110
1211000
DISCUSSION

AS is a common inflammatory rheumatic disease. The first symptoms occur before the age of 30 in 80% of patients and after the age of 45 in less than 5% of patients[9]. Patients with the disease lasting more than 20 years, especially men, often have spinal structure and function damage and even loss of mobility[10]. When the cervical vertebra is overextended due to tracheal intubation or pressure ventilation, the spine is prone to fracture, leading to cervical spinal cord injury[11]. Therefore, to keep the head and neck neutral, awake fiberoptic intubation is the safest option for these patients.

When nasotracheal intubation is performed, the nasal cavity should be pretreated before intubation. To this end, a cotton swab soaked in a mixture of 2% lidocaine and 3% ephedrine or 0.25% phenylephrine may be placed in the patient's nasal cavity[12]. Topical anesthesia of the larynx and lower airway must be administered through thyrocricocentesis, which provides better airway anesthesia and shortens the awake intubation time, but increases the risk of airway injury[13]. For patients with cervical fusion and fixation, thyrocricocentesis becomes complicated, and in these cases, atomization inhalation of lidocaine can be used for surface anesthesia of the lower airway.

Good airway suction and dryness are required for awake fiberoptic intubation. To achieve this, anticholinergic drugs may be administered before anesthesia, and secretions should be fully absorbed during intubation. Reducing oral secretions facilitates the absorption of local anesthetics during topical airway anesthesia. In addition, excessive secretion blocks the operator's vision and affects fiber optic intubation[14]. It is suggested that penehyclidine hydrochloride (0.01 mg/kg) be injected intramuscularly 30 min before the operation to inhibit salivary gland and airway gland secretions.

Patients with a difficult airway may undergo awake tracheal intubation (ATI). Rational drug sedation can reduce anxiety and discomfort in patients and increase their tolerance to the intubation process[15]. The most commonly used sedation solution is a combination of fentanyl (2 µg/kg) and midazolam (0.02 mg/kg), titrated according to the patient's needs[16]. Midazolam is used for sedation and prevention of seizures in cases of local anesthetic poisoning. Fentanyl inhibits airway reflexes, especially the cough response[14]. The cough reflex is an important factor affecting safe and smooth ATI and is an important indicator of the quality of awake fiberoptic intubation[17]. Sufentanil is difficult to titrate without excessive sedation and respiratory depression due to its high receptor efficiency[14], and therefore, it is not recommended. Remifentanil, as a single drug, can significantly improve the quality of intubation while shortening the time. However, the incidence of discomfort and memory of pain in patients during intubation with remifentanil is higher compared to midazolam, suggesting better sedative and anterograde amnesia properties of the latter[18].

Compared with fentanyl, dexmedetomidine provides better intubation conditions, lower hemodynamic response, and higher patient tolerance and satisfaction[19,20]. Dexmedetomidine in the dose range of 0.2 to 0.7 µg/kg/h did not inhibit respiration and maintained SpO2 within the normal range[21]. We usually infuse a 0.5 µg/kg loading dose for 10 min for ATI, combined with fentanyl (1 µg/kg) and midazolam (0.02). This combination provides the appropriate sedation and comfort and is well tolerated.

The degree of sedation is measured using the Ramsay sedation classification or modified OAA/S score. Kundra et al[7] monitored the facial grimace and airway reactivity scores during ATI, which provided a better evaluation of patient sedation, comfort level, and intubation conditions compared to the Ramsay sedation grade and improved OAA/S score. During ATI, we often use a modified scale to evaluate patient response.

BB has great advantages in patients who need nasotracheal intubation or have abnormal airways requiring one-lung ventilation. It can be quickly inserted through the established single-lumen ETT during the operation, unlike the DLT, which is difficult to use in such cases. Moreover, in difficult airways, BB allows the placement of a single-lumen ETT using various techniques incompatible with DLT[22,23].

The 9.0 Fr Tappa BB is recommended for use in adults with a single-lumen ETT with an inner diameter of 8.0 or 8.5 mm. An ETT with an inner diameter of 7.0 mm and a vasoconstrictor can reduce epistaxis during nasal intubation. We found that epistaxis during nasotracheal intubation can be reduced by rotating the ETT less than 90° counterclockwise, so that the tip of the tube is located on the outer side of the nasal cavity. This may be related to the distribution and location of blood vessels in the nasal cavity.

In conclusion, accurate preoperative identification and evaluation are critical for DA. For AS patients with cervical and thoracic kyphosis deformities and difficulty opening their mouth, who need one-lung ventilation, awake fiberoptic nasotracheal intubation is the best option. Lidocaine (2%) combined with ephedrine (3%) is recommended for nasal cavity treatment. Penehyclidine hydrochloride injection before anesthesia can effectively reduce oral secretions during intubation. Intravenous infusion of dexmedetomidine, fentanyl, and midazolam before intubation can improve the intubation conditions and patient tolerance. Once the airway is established, a separate BB can be used for effective one-lung ventilation (Figure 5).

Figure 5
Figure 5 After nasotracheal intubation, a bronchial blocker was used for one-lung ventilation.
CONCLUSION

AS 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.

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.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Anesthesiology

Country/Territory of origin: China

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P-Reviewer: Chen ZH S-Editor: Ma YJ L-Editor: Wang TQ P-Editor: Li X

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