Awake Flexible Scope Intubation in Critically Ill Patients With Physiologically Difficult Airways: A Prospective,...

Asleep tracheal intubation is a potentially dangerous intervention in critically ill patients. Patients at high-risk of severe hypoxemia or hemodynamic collapse have a "physiologically difficult airway." This study aimed to evaluate the procedural success and maintenance of physiologic stability associated with awake flexible scope intubation in these patients.

Prospective single-center observational case series.

Tertiary critical care unit.

Adults 18 years old or older requiring intubation who were considered to have a "physiologically difficult airway."

All patients underwent awake intubation under topical anesthesia. The primary outcome was a composite endpoint consisting of first-pass success and the absence of serious physiologic events, defined as severe hypoxemia (pulse oximetry saturation [Spo2] < 80%), hypotension (mean arterial pressure [MAP] < 60 mm Hg), hypertension (MAP > 120 mm Hg), new arrhythmia, or cardiac arrest. Continuous recording of the bedside monitor, time points during intubation, and six aspects of cooperation were documented.

All 39 patients had successful intubation on first attempt (100%). Of those fully studied, 25 of 36 (69.4%) met the composite endpoint: intubation plus physiologic stability. There were no arrhythmias or arrests. Spo2 decreased from baseline of 98% to 95% (p < 0.001) with one patient recording a Spo2 less than 80%. Peak heart rate increased from baseline of 95-105 beats/min (p < 0.001). MAP changed from baseline 87 mm Hg to lowest, 72 mm Hg (p < 0.001) and highest, 98 mm Hg (p < 0.001). Four patients had a recorded MAP less than 60 mm Hg (11%), and six patients had a MAP greater than 120 mm Hg (17%), but nine of the ten of these hemodynamic events lasted less than 30 seconds.

In critically ill patients with a physiologically difficult airway requiring intubation, awake flexible scope intubation may be an alternative to asleep tracheal intubation to help preserve hemodynamics. Further studies are needed to validate these findings.