title: Awake fiberoptic intubation and self-positioning in patients at risk of secondary cervical injury: a pilot study.
abstract: BACKGROUND
  This study was designed to document the feasibility of self-positioning after awake fiberoptic intubation of the trachea using primarily effective topical anesthesia rather than sedation.
  
  
  METHODS
  We investigated 14 patients (ASA physical status 1 to 3) with a neurosurgical diagnosis of cervical instability or at risk of secondary cervical injury, who were scheduled for awake fiberoptic intubation and self-positioning prone. Topical anesthesia was accomplished using an oropharyngeal spray of lidocaine alone or in combination with a transtracheal injection of lidocaine for awake fiberoptic intubation and self-positioning prone. Patients evidencing anxiolysis were given midazolam 2 to 4 mg, i.v.. We assessed the need for sedation, tolerance of the endotracheal tube, patient comfort, incidence of coughing or gagging, and changes in heart rate, blood pressure, and oxygen saturation. In addition, patients were interviewed on the first postoperative day and asked to categorize the experience of awake intubation and positioning as a positive, neutral, or negative experience, or to have no recall.
  
  
  RESULTS
  Eleven of the 14 patients turned themselves prone after awake fiberoptic intubation. No additional sedation was necessary for accomplishing positioning. Whereas 50% of the patients (7/14) showed mostly slight coughing or gagging during fiberoptic intubation, none of the patients who were positioned awake had coughing or gagging during tube fixation and prone positioning. The technique was unsuccessful in 3 patients. None of the patients viewed this as a negative experience.
  
  
  CONCLUSIONS
  Our study demonstrates that awake fiberoptic intubation and patient self-positioning was feasible in this sample of patients at risk of secondary cervical injury. This technique may extend the opportunity of continuous neurological monitoring in patients with a risk of position-related cervical injury, especially where electrophysiological monitoring is not possible or is unavailable.
authors.affiliation: Department of Anaesthesia, Intensive Care and Pain Therapy, Klinikum St. Georg gGmbH, Leipzig, Germany. michael_mal@hotmail.com
authors.forename: Michael Joerg
authors.initials: MJ
authors.lastname: Malcharek
authors.forename: Birgit
authors.initials: B
authors.lastname: Rogos
authors.forename: Stefan
authors.initials: S
authors.lastname: Watzlawek
authors.forename: Oliver
authors.initials: O
authors.lastname: Sorge
authors.forename: Armin
authors.initials: A
authors.lastname: Sablotzki
authors.forename: Jochen
authors.initials: J
authors.lastname: Gille
authors.forename: C Philip
authors.initials: CP
authors.lastname: Larson
mesh_terms: D000328:Adult; D000368:Aged; D000779:Anesthetics, Local / Q000008:administration & dosage; D002574:Cervical Vertebrae; D005240:Feasibility Studies; D005260:Female; D005336:Fiber Optic Technology / Q000379:methods*; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008012:Lidocaine / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods; D056888:Patient Positioning / Q000379:methods*; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D010865:Pilot Projects; D016684:Prone Position; D011446:Prospective Studies; D012306:Risk; D013122:Spinal Diseases; D014851:Wakefulness
chemical_list: D000779:Anesthetics, Local; D008012:Lidocaine