Comparison of spontaneous versus

paralyzed technique during Fiber-

optic intubation in patients of
difficult intubation with limited/no
mouth opening: Randomized parallel
group trial

Dr. Roopa
Dr. Dalim K Baidya
 Background
• Cause for restricted mouth opening in children is
TMJ ankylosis, maxillofacial tumors, fractures
• In adults awake Fibre optic intubation is preferred
whereas it is difficult in children so it is done after
anesthetizing
• Use of muscle relaxant is debatable, spontaneous
technique is considered safer
• However no literature is available and no
Randomised control trial done
 Research Hypothesis
• Incidence of difficult fibre optic
intubation is less in
anesthetized paralyzed technique
over anesthetized spontaneous
technique
 Aims and Objectives
Aim:
• To compare the incidence of difficult FO
intubation between anesthetized spontaneous
versus anesthetized paralyzed technique in
patients of difficult intubation with limited/no
mouth opening
 Objectives
• Primary Objective
– To compare the incidence of Difficult FO intubation
• Secondary Objectives
– Time to glottis
– Time to carina
– Time to intubation
– Blood in FO field
– Hemodynamic response to intubation
– Post operative sore throat
 Methods
• Study design: randomized parallel group trial
• Study population/ Inclusion criteria –
– Children and Adolescents (up to 18 years) with
– Difficult intubation and limited/no mouth opening
(<1.5cm)
 Methods
• Exclusion criteria
– Planned awake intubation (severe retrognathia with
features of upper airway obstruction during sleep)
 Methods
Groups
• Control – anesthetized spontaneously
breathing (fenta 1mcg/kg, propofol, oxygen-
air-isoflurane)
• Intervention – Anesthetized paralyzed (fenta
1mcg/kg, propofol, atracurium 0.5mg/kg or
succinylcholine 2mg/kg, oxygen-air-
isoflurane)
 Methods
• Preoperative check up
• Fasting
• Nasal vasoconstrictor
• Pre-oxygenation
• Induction of anesthesia
• Assisted mask ventilation
• Oxygenation and anesthesia maintained via NPA
• FO through other nostril
 Outcomes
• Incidence of Difficult FO intubation –
Composite incidence of two or more attempts,
desaturation < 95%, vocal cords not open, coughing
or movement
• Time to glottis
• Time to carina
• Time to intubation
• Blood in FO field
• Hemodynamic response to intubation
• Post op sore throat (incidence and severity grading)
 Sample size
• From our database incidence of difficult FO
intubation in such patients is 40%. Proposed
intervention expected to reduce the incidence
to 10%.
• With alpha error 0.05, power of 80%,
calculated sample size is 62.
Thank You