Background and Aim: Fiberoptic intubation is the gold standard technique for airway management in patients with difficult standard direct laryngoscopy, performed either awake or under sedation. The aim of sedation is to facilitate patient comfort and satisfaction, and to alleviate patient anxiety. Aim of this prospective randomized comparative study was to compare three different methods of topical anaesthesia under sedation, namely transcricoid injection, spray as you go, nebulisation of lignocaine with respect to intubation grading scale, severity scale, intubation time and complications in patients undergoing intubation.

Methodology: Ninety ASA grade 1 or 2 patients of either sex aged 20-50 yrs scheduled for elective surgery were equally divided into three groups(n=30), received 0.1% xylometazoline in both nostrils then 10% lignocaine by spraying the nares and posterior pharyngeal wall. Thereafter patients received 4ml of 4% lignocaine either by trancscricoid injection in group A, or via spray as you go method in group B, or via nebulization 15 min prior to procedure in group C. Intubation time, intubation grading scale, grading of overall intubating condition, cough counts, stridor, extra local anaesthetic requirement and were recorded. Patients were asked to score the procedure using severity score. Patients were monitored continuously for vital parameters blood pressure, SpO2, ECG, pulse rate.

Results: Group A patients showed better severity scale (p<0.01), shorter intubation time, lower incidence of coughing and stridor, didnot require extra dose of local anaesthetic and were maintained PR, BP, SpO2. The endoscopist intubation grading scale and grading of overall intubating conditions were better in Group A (p<0.01) than Group B&C.

Conclusion: In conclusion transcricoid injection of local anaesthetic was safe, providing effective local anaesthesia and was preferred by both patient and endoscopist.

Keywords: Fiberoptic intubation, lignocaine.

1. Benumof J. Management of the difficult adult airway with special emphasis on awake tracheal intubation. Anaesthesiology 1991;75:1087-110.
2. Graham DR, Hay JG, Clague J, et al. Comparison of three different methods used to achieve local anaesthesia for fiberoptic bronchoscopy. Chest 1992;102:704-7.
3. Malcharek MJ, Bartz M, Rogos B, Günther L, Sablotzki A, Gille J, Schneider G. Comparison of Enk Fibreoptic Atomizer with translaryngeal injection for topical anaesthesia for awake fibreoptic intubation in patients at risk of secondary cervical injury: A randomised controlled trial. Eur J Anaesthesiol. 2015 Sep;32(9):615-23.
4. Webb AR, Fernando SSD, Dalton HR. Arrowsmith JE, Wood head MA, Cumrnin ARC. Local anaesthesia for fibreoptic bronchoscopy: transcricoid injection or spray as you go' technique? Thorax 1990;45:474-77.
5. Gupta B, Kohli S, Farooque K, et al. Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer. Saudi Journal of Anaesthesia. 2014;8(Suppl 1):S15-S19.
6. Issac P A, Barry JE, Vaughan RS, Rosen M, Newcombe RG. A jet nebuliser for delivery of topical anaesthesia to the respiratory tract A comparison with cricothyroid puncture and direct spraying for fibreoptic bronchoscopy. Anaesthesia, 1990 Jan;45(1):46-8.
7. Putinati S, Ballerin L. Patient satisfaction with conscious sedation for bronchoscopy. Chest. 1999;115(5):1437-40.
8. Matot I, Kramer MR. sedation in outpatient bronchoscopy. Respir Med, 2000;94(12):1145-53.
9. Grendelmeier P, Kurer G, Pflimlin E, Tamm M, Stolz D. Feasibility and safety of propofol sedation in flexible bronchoscopy. Swiss Med Wkly. 2011 Aug 26;141:w13248.
10. Stolz D, Kurer G, Meyer A. Propofol versus combined sedation in flexible bronchoscopy, a randomized non inferiority trial. Eur Respir J. 2009;34(5):1024-30.
11. Murphy P. A fiberoptic endoscope used for nasal intubation. Anaesthesia. 1967;22:489-91.
12. Chaudhari L S, Manjrekar R P, Kamat S K, Dasgupta D D. use of lignocaine in bronchoscopy. J Postgrad Med 1982;28:64.
13. Kundra P, Kutralam S, Ravishankar M. local anaesthesia for awake fiberoptic nasotracheal intubation. Acta anaesthesiol Scand 2000 May;44(5):511-6.
14. Chandra A, Banavaliker JN, Agarwal MK. Fibreoptic bronchoscopy without sedation: Is transcricoid injection better than the "spray as you go" technique?. Indian J Anaesth 2011;55:483-7.
15. Reasoner, Daniel & Warner, David & M. Todd, Michael & W. Hunt, Scott & Kirchner, Jerry. (1995). A Comparison of Anesthetic Techniques for Awake Intubation in Neurosurgical Patients. Journal of neurosurgical anesthesiology 1995;7(2):94-9.
16. Sethi N, Tarneja VK, Madhusudanan TP, Shouche S. Local anaesthesia for fiberoptic intubation : A comparision of three techniques. Med J Armed Forces India. 2005 Jan;61(1):22-5.
17. Mathur PR, Jain N, Kumar A, Thada B, Mathur V, Garg D.   Comparison between lignocaine nebulization and airway nerve block for awake fiberoptic bronchoscopy-guided nasotracheal intubation: a single-blind randomized prospective study.   Korean J Anesthesiol. 2017 Jan;70:e54.

Naresh Kumar Sharma

Resident, Department of Anaesthesia, Sardar Patel Medical College & AGH, Bikaner, Rajasthan

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