Remimazolam for Sedation and Trachospray for Topicalization During Flexible Nasal Intubation in a Spontaneously Breathing Patient.

When a difficult airway is anticipated, awake tracheal intubation can be considered. Usually, low doses of sedatives are administered during this procedure for minimal sedation and anxiolysis, such as midazolam and remifentanil. The newly developed ultra-short-acting benzodiazepine remimazolam has a pharmacokinetic profile that is more suitable for titration during awake tracheal intubation than the long-acting midazolam. It can be titrated to effect while spontaneous breathing is preserved. When desired, cessation of administration will result in emergence from sedation in several minutes, but it can also be antagonized with flumazenil if needed. Here we report a case of a difficult airway in which awake nasal flexible intubation was performed using remimazolam for sedation: background infusion of 0.25 mg/kg/h with an initial bolus of 0.1 mg/kg and later extra boli of 0.04 mg/kg if needed. This was supplemented with a low dose of remifentanil (2 mcg/kg/hr). In addition, topical anesthesia of the upper airway was performed using a specifically designed device called the Trachospray, which nebulizes lidocaine into a fine mist that precipitates in the upper airway of the patient upon inhalation. About 4 ml of lidocaine 4% were inhaled via the Trachospray. An additional 2 ml of lidocaine 2% was sprayed via an epidural catheter advanced through the working channel of the endoscope for further topicalization of the epiglottis, vocal cords, and proximal portion of the trachea. This combination led to adequate anxiolysis and sedation, preservation of spontaneous breathing throughout the procedure, good conditions for successful intubation, and amnesia for the endoscopy and intubation. Further research is needed to establish the superiority of any of these techniques in comparison to other accepted methods.