Videolaryngoscope-assisted fibreoptic intubation in anticipated difficult airways of maxillofacial trauma: a prospective randomised comparison with videolaryngoscope-guided nasotracheal intubation.

BACKGROUND

Maxillofacial trauma poses airway management challenges due to edema, distorted facial anatomy and associated bleeding. Further, its fixation requires unhindered access to facial fractures, often necessitating securing the airway naso-tracheally during the intraoperative period. Traditional technique of nasotracheal intubation is associated with 17%-77% incidence of epistaxis. Fibreoptic bronchoscope helps guide nasotracheal tube under vision, decreasing incidence and severity of epistaxis. Moreover, as patients with maxillofacial trauma have difficult airways, every effort should be made to secure these challenging airways with best possible technique that increases first-attempt success rate. Use of fibreoptic bronchoscope as a part of hybrid videolaryngoscope-assisted fibreoptic intubation(VAFI) technique may provide these benefits. Hence, we conceptualized this study comparing the VAFI technique with traditional videolaryngoscope-assisted technique for securing nasotracheal tube in patients with anticipated difficult airways following maxillofacial trauma.

METHODS

Following a written, informed consent, we included adult patients with maxillofacial trauma, scheduled for fracture fixation under general anaesthesia, requiring nasotracheal intubation. All patients were randomised into two groups of 30 patients each, with patients in group-VLS undergoing videolaryngoscope-guided nasotracheal intubation, and patients in group-VAFI undergoing nasotracheal intubation using VAFI technique. Our primary objective was to assess first-pass intubation success rate and secondary objectives included incidence and severity of nasal bleeding/epistaxis, resistance to nasal passage of tracheal tube, time to successful intubation and number of intubation attempts.

RESULTS

Patients belonging to the VAFI group had significantly greater first-pass intubation success rate(90% vs. 60%; unadjusted p = 0.015; Bonferroni-adjusted p = 0.092), with significantly lower time to successful intubation(57 s vs. 120 s; p-value < 0.001) and decreased incidence of nasal bleeding(3.3% vs. 30%; p-value:0.01).

CONCLUSION

Flexible bronchoscope and videolaryngoscope, have both been individually used for securing anticipated difficult airways. A hybrid VAFI technique, can offset the shortcomings of individual techniques, providing best possible airway management strategy, enhancing first-pass intubation success rate and significantly lowering incidence of epistaxis.