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Dexmedetomidine for the management of awake fibreoptic intubation

  1. Xing-Ying He1,
  2. Jian-Ping Cao2,
  3. Qian He3,
  4. Xue-Yin Shi1,*

Editorial Group: Cochrane Anaesthesia Group

Published Online: 19 JAN 2014

Assessed as up-to-date: 9 MAY 2012

DOI: 10.1002/14651858.CD009798.pub2


How to Cite

He XY, Cao JP, He Q, Shi XY. Dexmedetomidine for the management of awake fibreoptic intubation. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD009798. DOI: 10.1002/14651858.CD009798.pub2.

Author Information

  1. 1

    Changzheng Hospital, The Second Military Medical University, Department of Anaesthesiology, Shanghai, China

  2. 2

    455 Hospital of the PLA, Department of Anaesthesiology, Shanghai, China

  3. 3

    The Second Military Medical University, Department of Health Statistics, Faculty of Health Services, Shanghai, China

*Xue-Yin Shi, Department of Anaesthesiology, Changzheng Hospital, The Second Military Medical University, Fengyang Road 415, Shanghai, 200003, China. shixueyin1128@163.com.

Publication History

  1. Publication Status: New
  2. Published Online: 19 JAN 2014

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Characteristics of included studies [ordered by study ID]
Bergese 2010a

MethodsDesign: randomized, double-blinded study

Setting: academic medical centre


Participants55 ASA physical status I, II, III and IV patients, aged 18 to 85 years, scheduled for non-emergency surgery with AFOI


InterventionsMDZ group (n = 24): Participants received IV midazolam 0.05 mg/kg with additional doses to achieve a Ramsay Sedation Scale (RSS) score of ≥ two

DEX-MDZ group (n = 31): Participants received midazolam 0.02 mg/kg followed by dexmedetomidine 1 μg/kg, then an infusion of dexmedetomidine 0.1 μg/kg/h and titrated to 0.7 μg/kg/h to achieve RSS ≥ two

Topical local anaesthetics were given


OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no reaction; two: slight grimacing; three: severe grimacing; four: verbal objection; five: defensive movement of head, hands or feet)

Airway obstruction (no details)

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)


NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'. It was generally assumed that if participants displayed heavy grimacing, verbal objection, defensive movement of head, hands or feet or prolonged cough, this could be considered as clinically significant discomfort

One of two trained, independent, study-blinded observers assessed participant discomfort during placement of the fibreoptic scope

No definition was provided for "airway obstruction", "hypoxia" or "treatment-emergent cardiovascular adverse events", but the study author mentioned in the Discussion section, "There were no complications reported in either patient group, and none of the 31 DEX-MDZ patients experienced any respiratory depression"


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomization schedule

Allocation concealment (selection bias)Unclear riskNo details

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Selective reporting (reporting bias)Unclear riskNot all expected outcomes reported

Other biasUnclear riskSmall sample size

Blinding of participants and personnel (performance bias)
All outcomes
Low riskDouble-blinded (participant and assessor)

Blinding of outcome assessment (detection bias)
All outcomes
Low riskDouble-blinded (participant and assessor)

Bergese 2010b

MethodsDesign: randomized, double-blinded, placebo-controlled study

Setting: 17 medical centres in the United States


ParticipantsAll adult patients undergoing AFOI for non-emergency surgery were potential candidates for this study. Patients were excluded from this study if they were:

  1. prisoners;
  2. pregnant;
  3. mentally ill;
  4. younger than 18 years of age;
  5. known or admitted alcohol or drug abusers; or
  6. allergic to the drugs involved in the study


InterventionsDexmedetomidine group (n = 47): Participants received a loading dose of 1.0 mcg/kg over 10 minutes followed by a continuous infusion of 0.7 mcg/kg-1/h-1.The study drug was started 15 minutes before airway topicalization for AFOI

Placebo group (n = 39): Participants received a loading dose and a maintenance infusion of 0.9% sodium chloride for injection at a volume and rate equal to those of dexmedetomidine. Fifteen minutes after the start of study drug infusion and before airway topicalization, any participant with Ramsay Sedation Scale < two received rescue midazolam to achieve targeted sedation (RSS ≥ two) before topicalization and throughout AFOI


OutcomesAirway obstruction

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)


NotesRSS (Ramsay Sedation Scale: one to six): 1: Participant is anxious and agitated or restless, or both; 2: Participant is cooperative, oriented and tranquil; three: Participant responds to command only; four: Participant exhibits brisk response to light glabellar (between the eyebrows) tap or loud auditory stimulus; five: Participant exhibits a sluggish response to light glabellar tap or loud auditory stimulus; six: Participant exhibits no response to stimulus

No definition was provided for "airway obstruction" or "hypoxia", but the study author mentioned in the Discussion that "Dexmedetomidine has no significant effect on respiratory function and gas exchange at the doses used in this trial"


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskParticipants were randomly assigned 1:1 to receive dexmedetomidine or placebo. No further details

Allocation concealment (selection bias)Unclear riskNo details

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Selective reporting (reporting bias)Unclear riskNot all expected outcomes reported

Other biasUnclear riskSmall sample size

Blinding of participants and personnel (performance bias)
All outcomes
Low riskDouble-blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskDouble-blinded

Chu 2010

MethodsDesign: randomized study. The intubating anaesthetist, participants and recorders were all blinded to each participant's group

Setting: academic medical centre


ParticipantsWe enrolled 30 oral cancer patients with limited mouth opening who were undergoing AFOI for elective surgery


InterventionsDex group (n = 16): Participants received dexmedetomidine (1.0 μg/kg-1) infusion

Control group (n = 14): Participants received fentanyl (1.0 μg/kg-1) infusion

Topical anaesthesia was performed after the middle of infusion


OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no movement; two: grimacing; three: mild cough; four: major limb movement; five: prolonged cough)

Intubation time (from insertion of fibreoptic scope to confirmation of nasal tracheal intubation)

Airway obstruction (Participants were assessed on a scale of one to three: one: patent airway; two: airway obstruction relieved by neck extension; three: airway obstruction requiring jaw retraction)

Hypoxia (SpO2 < 94%)

Treatment-emergent cardiovascular adverse events


NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'

It was generally assumed that if participants displayed heavy grimacing, verbal objection, defensive movement of head, hands or feet or prolonged cough, this could be considered as clinically significant discomfort. If participants required neck extension or jaw retraction, it could be considered as clinical significant airway obstruction

Two participants developed bradycardia (lowest heart rates were 48 and 45 beat/min), and one developed hypotension (78/46 mmHg) in the Dex group. No profound bradycardia (heart rate <40 beats/min) occurred in each group

Two experienced consultant anaesthetists certified in advanced airway life support performed airway management for all study participants


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskParticipants were allocated randomly to one of two groups via a computer-generated random number table

Allocation concealment (selection bias)Unclear riskNo details

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Selective reporting (reporting bias)Low riskAll expected outcomes reported

Other biasUnclear riskSmall sample size

Blinding of participants and personnel (performance bias)
All outcomes
Low riskThe consultant who performed AFOI, the participants and the postoperative recorder were all blinded to each participant's group

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe consultant who performed AFOI, the participants and the postoperative recorder were all blinded to each participant's group

Tsai 2010

MethodsDesign: randomized study. The intubating anaesthetist, participants and the study nurse who recorded details of the procedures were all blinded to the study

Setting: academic medical centre


ParticipantsForty participants with anticipated difficult airways and due to undergo tracheal intubation for elective surgery were enrolled


InterventionsDexmedetomidine group (n = 20): Participants received a loading dose of dexmedetomidine (1.0 μg/kg-1) infused over 10 minutes

Propofol group (n = 20): Participants received propofol. The initial target effect site concentration (Ce) was set at 3 μg/mL-1. This was adjusted by 1.0 μg/mL-1 according to participant comfort during the procedure. If a comfort score exceeded three or a persistent cough occurred during the procedure, the TCI was titrated upwards, after which the intubating anaesthetist waited for 60 s before proceeding. While waiting for the desired level of sedation to be achieved, topical anaesthesia was applied to the airway


OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no reaction; two: slight grimacing; three: heavy grimacing; four: verbal objection; five: defensive movement of head or hands)

Intubation time (time taken from insertion of the fibreoptic scope to confirmation of nasotracheal intubation)

Airway obstruction (Participants were assessed on a scale of one to three: one: patent airway; two: airway obstruction relieved by neck extension; three: airway obstruction requiring jaw retraction)

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)


NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'

It was generally assumed that if participants displayed heavy grimacing, verbal objection, defensive movement of head, hands or feet or prolonged cough, this could be considered as clinically significant discomfort. If participants required neck extension or jaw retraction, this could be considered as clinically significant airway obstruction

No obvious definition was provided for "airway obstruction" or "hypoxia"

Two experienced consultant anaesthetists certified in advanced airway life support performed airway management for all study participants


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskParticipants were randomly allocated. No further details

Allocation concealment (selection bias)Unclear riskNo details

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo dropouts

Selective reporting (reporting bias)Low riskAll expected outcomes reported

Other biasUnclear riskSmall sample size

Blinding of participants and personnel (performance bias)
All outcomes
Low riskDouble-blinded

Blinding of outcome assessment (detection bias)
All outcomes
Low riskDouble-blinded

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Boyd 2011Three case reports

Swaniker 2011None of the outcomes were reported

 
Characteristics of studies awaiting assessment [ordered by study ID]
Cattano 2012

MethodsDesign: randomized, double-blinded study

Setting: a hospital affiliated with the Universtiy medical school

Participants34 adult ASA I to III participants who required AFOI. Because of case cancellations or delays, only 30 participants were included

InterventionsParticipants were randomly assigned by the pharmacy to one of two groups: group REM (remifentanil) and group DEX (dexmedetomidine). All participants received a loading dose at a rate of 0.1 mL/kg over 10 minutes and a continuous infusion at a rate of 0.1 mL/kg/h of their respective drug. Participants in group REM received a remifentanil loading dose of 0.75 mcg/kg, and participants in group DEX received a dexmedetomidine loading dose of 0.4 mcg/kg over 10 minutes. The continuous infusion was begun with participants
in group REM receiving remifentanil at 0.075 mcg/kg/min and those in group DEX receiving dexmedetomidine at 0.7 mcg/kg/h

OutcomesAirway obstruction (no details)

Hypoxia

Treatment-emergent cardiovascular adverse events

NotesNo definition was provided for "airway obstruction", "hypoxia" or "treatment-emergent cardiovascular adverse events", but the study author provided the details in "Results---Table 4"

Hu 2013

MethodsDesign: randomized, double-blinded study

Setting: a hospital affiliated with the Universtiy medical school

ParticipantsForty-two adult patients with American Society of Anesthesiologists (ASA) classifications of I to III were recruited for elective awake fibreoptic nasotracheal intubation following diagnosis of maxillofacial cancer or fracture with limited mouth opening. One patient declined consent, and one operation was cancelled

InterventionsForty participants undergoing elective awake fibreoptic nasotracheal intubation were allocated randomly to receive either dexmedetomidine (n = 20) or remifentanil (n = 20). Participants in the dexmedetomidine group received a loading dose (1.5 μg/kg) infused over 10 minutes followed by a continuous infusion of 0.7 μg/kg/h. Participants in the remifentanil group received remifentanil via an Orchestra Base Primea (Fresenius Vial) infusion system using a Minto pharmacokinetic model. The initial target was 3.0 ng/mL, and the TCI was adjusted by 0.5 ng/mL after the target concentration at the effect site had equilibrated with the plasma concentration until the desired level of sedation was achieved

OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: grimacing; two: localizing; three: coughing on lidocaine via scope; four: coughing on entering infraglottic space; five: prolonged coughing)

Intubation time (from insertion of fibreoptic scope to confirmation of nasal tracheal intubation)

Airway obstruction (no details)

Hypoxia

Treatment-emergent cardiovascular adverse events

NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'

It was generally assumed that if participants displayed coughing on lidocaine via scope or on entering infraglottic space or prolonged cough, this could be considered as clinically significant discomfort

No definition was provided for "airway obstruction" or "hypoxia"

Two consultant anaesthetists were present during all procedures. One was responsible for performing the awake nasal fibreoptic intubation and scoring sedation, endoscopy, intubation and postintubation conditions; the other administered the study drugs. An anaesthetist nurse collected anaesthetic data and postoperative records. The intubating anaesthetist, the participants and the nurse anaesthetist were all blinded to the study drugs used

Li 2012

MethodsDesign: randomized, double-blinded study

Setting: a hospital affiliated with the Universtiy medical school

ParticipantsThirty participants with an anticipated difficult airway caused by huge goitre were enrolled and randomly divided into dexmedetomidine group (n = 15) and propofol group (n = 15)

InterventionsParticipants in the dexmedetomidine group received a loading dose of dexmedetomidine (1.0 μg/kg-1), infused over 10 minutes, then pumped at a continuous rate of 0.4 μg/kg -1/h-1. Participants in the propofol group received a loading dose of 2.0 mg/kg-1 pumped at a continuous rate of 5 to 8 mg/kg-1/h-1

OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no reaction; two: slight grimacing; three: severe grimacing; four: verbal objection; five: defensive movement of head, hands or feet)

Airway obstruction

Hypoxia

Treatment-emergent cardiovascular adverse events

NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'. It was generally assumed that if participants displayed heavy grimacing, verbal objection, defensive movement of head, hand or feet or prolonged cough, this could be considered as clinically significant discomfort

No definition was provided for "airway obstruction", "hypoxia" or "treatment-emergent cardiovascular adverse events", but the study author provided the details in the Results

Two consultant anaesthetists: One was responsible for performing the awake nasal fibreoptic intubation and scoring sedation, endoscopy, intubation and postintubation conditions, and the other administered the study drugs. A resident anaesthetist collected anaesthetic data and postoperative records. The intubating anaesthetist and the resident anaesthetist were all blinded to the study drugs used

Qiu 2013

MethodsDesign: randomized, double-blinded study

Setting: a hospital affiliated with the Universtiy medical school

ParticipantsSixty participants with difficult airway and Mallampati score >= III were selected and randomly divided into four groups (D1, D2, D3 and MF, n = 15) by simple random method Nasal intubation with fibreoptic bronchoscopy was performed in all participants

InterventionsParticipants in groups D1, D2 and D3 intravenously received 0.5, 1.0 and 1.5 μg/kg dexmedetomidine 15 minutes before intubation, respectively. Participants in group MF were intravenously treated with 0.02 mg/kg midazolam and 2.0 μg/kg fentanyl five minutes before intubation

OutcomesDiscomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no movement; two: grimacing; three: mild cough; four: major limb movement; five: prolonged cough)

Intubation time (from insertion of fibreoptic scope to confirmation of nasal tracheal intubation)

Airway obstruction

Hypoxia

Treatment-emergent cardiovascular adverse events

NotesWe converted ordinal outcome measures to dichotomous outcome measures by identifying cut-off points on rating scales and dividing participants accordingly into 'clinical significant response' or 'no clinical significant response'. It was generally assumed that if participants displayed major limb movement or prolonged cough, this could be considered as clinically significant discomfort

One researcher was responsible for performing the awake nasal fibreoptic intubation and for scoring sedation, endoscopy, intubation and postintubation conditions, another administered the study drugs and the third collected anaesthetic data and postoperative records. All were blinded to the study drugs used

 
Table 1. Raw data for Chu 2010

FOI comfort (1, 2, 3, 4, 5)DexmedetomidineFentanyl

160

252

357

404

501

 
Table 2. Raw data for Tsai 2010

FOI comfort (1, 2, 3, 4, 5)DexmedetomidinePropofol

170

299

336

413

502

 
Table 3. Table 1

Primary outcomeDiscomfort during awake fibreoptic intubation

Bergese 2010aDexmedetomidine group reacted less (P < 0.001)

Bergese 2010bNot reported

Chu 2010No significant difference between groups

Tsai 2010Dexmedetomidine group reacted less (P < 0.05)

 
Table 4. Table 2

Secondary outcomeIntubation timeAirway obstructionHypoxiaTreatment-emergent cardiovascular adverse events

Bergese 2010aNot reportedNot clearly reportedNo significant difference between groupsNo significant difference between groups

Bergese 2010bNot reportedNot clearly reportedNo significant difference between groupsNo significant difference between groups

Chu 2010No significant difference between groupsNo significant difference between groupsNo significant difference between groupsNo significant difference between groups

Tsai 2010No significant difference between groupsNo significant difference between groupsNo significant difference between groupsNo significant difference between groups

 
Table 5. Results of included studies

StudyInterventionsOutcomesMain results

Bergese 2010aMDZ group (n = 24): Participants received IV midazolam 0.05 mg/kg with additional doses to achieve a Ramsay Sedation Scale (RSS) score ≥ two

DEX-MDZ group (n = 31): Participants received midazolam 0.02 mg/kg followed by dexmedetomidine 1 μg/kg, then an infusion of dexmedetomidine 0.1 μg/kg/h and titrated to 0.7 μg/kg/h to achieve RSS ≥ two

Topical local anaesthetics were given
Discomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no reaction; two: slight grimacing; three: severe grimacing; four: verbal objection; five: defensive movement of head, hands or feet)

Airway obstruction (no details)

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)
DEX-MDZ participants reacted less to AFOI than did MDZ participants (P < 0.01)

No complications were reported in either participant group, and none of the 31 DEX-MDZ participants experienced respiratory depression

Bergese 2010bDexmedetomidine (n = 47): Participants received a loading dose of 1.0 mcg/kg over 10 minutes, followed by a continuous infusion of 0.7 mcg/kg-1/h-1. The study drug was started 15 minutes before airway topicalization for AFOI

Placebo group (n = 39): Participants received a loading dose and a maintenance infusion of 0.9% sodium chloride for injection at a volume and rate equal to that of dexmedetomidine. Fifteen minutes after the start of the study drug infusion and before airway topicalization, any participant with Ramsay Sedation Scale < two received rescue midazolam to achieve targeted sedation (RSS >= two) before topicalization and throughout AFOI
Airway obstruction

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)
Dexmedetomidine has no significant effect on respiratory function and gas exchange at the doses used in this trial. Dexmedetomidine is well tolerated and does not compromise the airway

Seven dexmedetomidine-treated participants (12.7%) and four placebo-treated participants (8.0%) received intravenous fluid bolus or medication to treat blood pressure or HR during study drug infusion

Chu 2010Dex group (n = 16): Participants received dexmedetomidine (1.0 μg/kg-1) infusion

Control group (n = 14): Participants received fentanyl (1.0 μg/kg-1) infusion

Topical anaesthesia was performed after the middle of infusion
Discomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no movement; two: grimacing; three: mild cough; four: major limb movement; five: prolonged cough)

Intubation time (from insertion of fibreoptic scope to confirmation of nasal tracheal intubation)

Airway obstruction (Participants were assessed on a scale of one to three: one: patent airway; two: airway obstruction relieved by neck extension; three: airway obstruction requiring jaw retraction)

Hypoxia (SpO2 < 94%)

Treatment-emergent cardiovascular adverse events
No differences between the two groups were noted for discomfort during awake fibreoptic intubation, intubation time, airway obstruction, hypoxia or treatment-emergent cardiovascular adverse events

Tsai 2010Dexmedetomidine group (n = 20): Participants received a loading dose of dexmedetomidine (1.0 μg/kg-1) infused over 10 minutes

Propofol group (n = 20): Participants received propofol. The initial target effect site concentration (Ce) was set at 3 μg/mL-1. This was adjusted by 1.0 μg/mL-1 according to participant comfort during the procedure. If a comfort score exceeded three or a persistent cough occurred during the procedure, the TCI was titrated upwards, after which the intubating anaesthetist waited for 60 seconds before proceeding. While waiting for the desired level of sedation to be achieved, topical anaesthesia was applied to the airway
Discomfort during awake fibreoptic intubation (Participants were assessed on a scale of one to five: one: no reaction; two: slight grimacing; three: heavy grimacing; four: verbal objection; five: defensive movement of head or hands)

Intubation time (time taken from insertion of the fibreoptic scope to confirmation of nasotracheal intubation)

Airway obstruction (Participants were assessed on a scale of one to three: one: patent airway; two: airway obstruction relieved by neck extension; three: airway obstruction requiring jaw retraction)

Hypoxia (no details)

Treatment-emergent cardiovascular adverse events (no details)
DEX participants reacted less to AFOI than did the propofol participants (P < 0.01)

No differences between the two groups were noted for intubation time or hypoxia

The dexmedetomidine group experienced fewer airway events and less heart rate response than did the propofol group (P < 0.003 and P value 0.007,respectively)