Awake Versus Asleep Intubation for Mediastinal Goiters: A Systematic Review and Meta-Analysis

ImportanceMediastinal goiters can complicate anesthetic management, and although awake bronchoscopic intubation is the gold standard, it is resource-intensive and may be unpleasant for patients. In many centers across North America, patients undergoing thyroidectomy for mediastinal goiters are routinely intubated awake.ObjectiveThis study aimed to evaluate the outcomes of intubation in patients selected for awake versus asleep intubation for thyroidectomy of mediastinal goiters.DesignPRISMA 2020 Checklist for systematic reviews was followed. A search was performed in the Medline, Embase, Web of Science, CINAHL, Scopus, and Cochrane databases. Two independent reviewers performed abstract and full-text review. Data were extracted in duplicate. Study quality was assessed using the JBI Critical Appraisal tool. To account for heterogeneity, a 3-level random-effects model was constructed using the Der Simonian and Laird method with an arcsine transformation.Setting and ParticipantsPatients undergoing thyroidectomy for benign mediastinal goiters.Intervention and ExposuresAwake or asleep intubation.Main Outcome(s) and Measure(s)Rate of failed intubations in asleep intubation and proportion of uncomplicated intubations in asleep and awake populations.ResultsTwelve of 490 identified studies, involving 1002 patients, were included. Three cases of failed intubations were found in the asleep intubation group, with an overall incidence of failed intubation of 0.3%. Meta-analysis demonstrated an overall uncomplicated intubation rate of 91% (95% CI 77%-98%, n = 1002). Subgroup analyses showed a 96% success rate (95% CI 73%-100%, n = 60) for awake intubations and 88% (95% CI 69%-98%, n = 942) for asleep intubations. Further refined analyses showed uncomplicated intubation rates of 98% (95% CI 93%-100%, n = 469) for asleep, and 92% (95% CI 78%-99%, n = 48) for awake groups.Conclusions and RelevanceThe risk of failed intubation in patients with mediastinal goiters remains low, and awake intubation may require more attempts than asleep intubation. Further research with standardized definitions of intubation difficulty is needed.