No/Anaesthesiology

FROM, DR. PAMPAPATHI.R Place:Bellary P.G. IN ANAESTHESIOLOGY Date:15-11-2007DEPT OF ANAESTHESIOLOGY VIMS, BELLARYPIN-583104

TO,THE PRINCIPAL,VIJAYNAGAR INSTITUTE OF MEDICAL SCIENCES,BELLARY. THROUGH PROPER CHANNEL Respected sir,

Sub: ACCEPTANCE, REGISTRATION AND FORWARDING OF TOPIC In accordance of the above cited topic, I the undersigned studying in P.G course in

M.D DEGREE IN ANAESTHESIOLOGY have been allotted the Dissertation topic “A

STUDY OF NASOTRACHEAL FIBEROPTIC INTUBATION UNDER

LOCAL ANAESTHESIA” under the guidance of DR. A.SRINIVAS

MURTHY, M.D. Professor & HOD, Department of Anaesthesiology, VIMS,

Bellary.

I request you to kindly forward the dissertation topic in the prescribed form

to the university for approval.

Thanking you, Yours faithfully

(DR. PAMPAPATHI.R)

GUIDE

FROM,THE PROF, AND HEAD OF THE DEPARTMENTDEPARTMENT OF ANAESTHESIOLOGY,VIMS, BELLARY.

TO,THE PRINCIPAL,VIJAYNAGAR INSTITUTE OF MEDICAL SCIENCES,BELLARY. Through proper channel Sir, As per the regulations of the university of the Dissertation topic, the

following post graduate student in M.D DEGREE IN ANAESTHESIOLOGY has

been allotted the Dissertation topic as follows by the official registration

committee of all qualified and eligible guides of the Department of

Anaesthesiology

NAME TOPIC GUIDEDR. PAMPAPATHI.R

P.G IN

ANAESTHESIOLOGY

DEPARTMENT OF

ANAESTHESIOLOGY

VIMS, BELLARY

PIN-583104

A STUDY OF

NASOTRACHEAL

FIBEROPTIC

INTUBATION UNDER

LOCAL ANAESTHESIA

DR.A.SRINIVAS MURTHY. M.D.

PROFESSOR & HOD

DEPT.OF.ANAESTHESIOLOGY

VIMS, BELLARY

Therefore I request you kindly to communicate the acceptance of the dissertation topic allotted to the P.G student at an early date.

Thanking you Yours faithfully,

FROM,THE PROF, AND HEAD OF THE DEPARTMENTDEPARTMENT OF ANAESTHESIOLOGY,VIMS, BELLARY.

TO,THE REGISTRAR,RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE,KARNATAKA.

Sir, Through proper channel As per the regulations of the university of the Dissertation topic, the following post graduate student in M.D DEGREE IN ANAESTHESIOLOGY has been allotted the Dissertation topic as follows by the official registration committee of all qualified and eligible guides of the Department of Anaesthesiology

NAME TOPIC GUIDEDR. PAMPAPATHI.R

P.G IN

ANAESTHESIOLOGY

DEPARTMENT OF

ANAESTHESIOLOGY

VIMS, BELLARY

PIN-583104

A STUDY OF

NASOTRACHEAL

FIBEROPTIC

INTUBATION UNDER

LOCAL ANAESTHESIA

DR.A.SRINIVAS MURTHY. M.D

PROFESSOR & HOD

DEPT.OF.ANAESTHESIOLOGY

VIMS, BELLARY

Therefore I request you kindly to communicate the acceptance of the dissertation topic allotted to the P.G student at an early date.

Thanking you Yours faithfully,

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALROE, KARNATAKA

ANNEXURE – II

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the candidate

and Address

(In Block Letters)

DR. PAMPAPATHI.R

P.G. IN ANAESTHESIOLOGY

DEPT OF ANAESTHESIOLOGY

VIMS, BELLARY

PIN – 583 104

2. Name of the Institute VIJAYANAGAR INSTITUTE OF MEDICAL

SCIENCES, BELLARY, KARNATAKA.

3. Course of Study and

Subject

MEDICAL – M.D. IN ANAESTHESIOLOGY

4. Date of Admission to

Course

12-04-2007

5. Title of Topic “A STUDY OF NASOTRACHEAL

FIBEROPTIC INTUBATION UNDER

LOCAL ANAESTHESIA”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY

- The most common cause of mortality and serious morbidity due to

anesthesia is from airway problems. It is estimated that one third of all

anesthetic deaths are due to failure to intubate and ventilate (1).

During routine anesthesia the incidence of difficult tracheal intubation has

been estimated at 3 - 18% (2,7).

Direct laryngoscopy by McIntosh laryngoscope at times presents difficulty

in intubation in conditions like- limited jaw movement,micrognathia,morbid

obesity,cervical spinal problems and inability to open mouth eg—

intermaxillary fixation, Temporomandibular joint trauma,rheumatoid

arthritis (3,4).

The flexible fiberoptic endoscope is the most valuable single tool available

for the anesthesiologists to manage such conditions. The flexible fiberoptic

intubation gives the competent practitioner the unparallel opportunity to

secure almost any difficult airway encountered (5).

Fiberoptic intubation via nasal route is usually easier and has a higher

success rate compared with an oral approach. The main advantage of nasal

approach is a straight route to larynx and trachea and the endotracheal tube

passes more easily. Another beneficial effect of nasal approach is the

stability of endotracheal tube once it has been secured in position (6).

Awake fiberoptic intubation under local anaesthesia is now an accepted

technique for managing the difficult airway because

a) safety is maximum as patient can sustain ventilation and oxygenation

without assistance.

b) Under general anaesthesia, pharyngeal muscles relax, causing soft

tissue obstruction that limits visualization.

c) Awake patient can swallow secretions and keep their pharynx clear.

The principal patient complaints of awake nasal fiberoptic intubation

include sensation of passage of the instrument through the nose and larynx,

pain and coughing while endoscopists usually ascribe difficulty in laryngeal

visualization to secretions. Adequate local anaesthesia will reduce this

problem (8,9,10).

Hence the present study is undertaken to evaluate the intubating conditions,

patient comfort and haemodynamic changes during awake nasotracheal

fiberoptic intubation.

6.2 REVIEW OF LITERATURE

Difficult airway management raises a great amount of debate among

anaesthesiologists because of high morbidity and mortality rates associated

with difficult intubation (11).

Fiberoptic intubation is preferred for the management of difficult airways,

but recommendations vary. Some authors recommend performing

fiberoptic intubation in an awake or lightly sedative patient (12,13,14).

Several local anaesthetic techniques have been proposed . Awake fiberoptic

intubation can be practiced with only nasal fossa local anaesthesia or with

regional anaesthesia and laryngeal block (15).

Sedation can be provided using benzodiazepines such as midazolam but

seem to be less promising than propofol because of their longer lasting

action and half life (16).

Opioids are used with local anesthesia in reducing laryngeal morbidity; few

studies propose opioids alone to increase tracheal tube tolerance with

fiberoptic intubation with remifentanil, fentanyl and alfentanil (17,18,19).

Laryngoscope and tracheal intubation (Direct laryngoscopy or Fiberoptic

intubation) after induction of anaesthesia often associated with severe

hypertension, increase in mean arterial pressure from 35 to 60 mm Hg

compared with preintubation values, have often been reported after

placement of an endotracheal tube. A properly performed awake technique

is well tolerated with minimal haemodynamic disturbances (20,21,22).

6.3 OBJECTIVES OF THE STUDY

A. To study the ease of intubation.

B. To study the patient comfort during the procedure.

C. To study the haemodynamic changes associated with the

procedure.

7. MATERIAL AND METHODS.

7.1 SOURCE OF DATA – The study is conducted in 50 patients of 20

to 50 yrs of age scheduled to undergo elective surgery under general

anaesthesia at VIMS Hospital Bellary. The study is conducted in the

department of Anaesthesiology VIMS Bellary for the period of one year

from 1-11-2007 to 31-10-2008

The patients are included in the study by applying the following

inclusion and exclusion criteria.

Inclusion criteria

a) Patients undergoing elective surgeries under general endotracheal

anaesthesia

b) Patients belonging to ASA grade I & II

c) Patients with Mallampatti airway grade I & II

Exclusion criteria

a) Patient refusal for the procedure

b) Patients with Malampatti airway Grade III & IV

c) Local infection in the nose

d) Significant deviated nasal septum and previous nasal surgeries

e) Coagulopathies

f) Patients with history of allergies/hypersensitivity to multiple drugs or

local anaesthetics or already taking opioid analgesic medication.

7.2 METHODS OF COLLECTION OF DATA – (Including sampling

procedure if any)

During the above said study period 50 patients posted for elective

surgeries under general anaesthesia will undergo awake fiberoptic

intubation via nasal route under local anaesthesia.

Patients are explained the procedure and informed/written consent

obtained.

- Routine preanaesthetic evaluation is performed. The more

patent nostril(right or left sided) is identified. Airway is

assessed thoroughly by Mallampatti classification..

- On arrival in the operating room, patient’s basal parameters-

B.P, heart rate and ECG are monitored using pulse oximetry,

NIBP and ECG monitor.

- Intravenous access is established and an IV infusion of Ringer

lactate started.

- Sterile fiberoptic scope with light source and appropriate

sized endotracheal tubes kept ready.

- Inj midazolam IV 0.04 mg/kg body wt given.

- Inj Glycopyrrolate 0.2 mg IV given

- 2 drops of nasal mucosal vasoconstrictor (Xylometazoline)

are instilled into each nostril as decongestants.

- 2cc of 2% lignocaine viscous solution soaked with gauge put

into each nostrils to anaesthetize the mucosa for 10 minutes.

- 10% lignocaine sprayed over tongue and posterior pharyngeal

wall using tongue depressor.

- Superior laryngeal nerve and recurrent laryngeal nerve blocks

are performed by external approach.

- An appropriate sized endotracheal tube fixed to the

fiberscope. After lubricating the fiberoptic scope, it is

introduced through endotracheal tube and passed into the

predetermined nostril with patient’s head in ‘sniffing of

morning’ position.

- Fibreoptic scope is advanced until vocal cords are seen. The

patient is then asked to take a deep breath and the

bronchoscope is passed through the cords. If this precipitates

coughing, additional lidocaine is sprayed through the working

channel of the bronchoscope.

- After passing through the vocal cords, the fiberscope is

advanced until the tracheal rings come into view. The carina

is identified.

- When the tip of the fiberscope is at the carina, the

endotracheal tube is passed into the trachea using fiberscope

as a guide. The scope is removed by holding endotracheal

tube in place.

- The endotracheal tube is connected to the Magill’s circuit and

assisted ventilation done. The endotracheal tube is secured

after confirming placement by 5 point auscultation and

capnography.

- The ease of intubation (number of attempts, time taken to

intubate from the time of insertion of fiberscope),

- The patient comfort (no movement, coughing, extremity

movement, violent movement, etc) are noted.

- Throughout the procedure and upto 10 minutes after

intubation, patient’s vitals- BP, heart rate, ECG and oxygen

saturation monitored.

7.3 Does the study require any investigation or intervention to be

conducted on patients or other humans or animals? If so please

describe briefly?

Yes, The following are done pre-operatively

Blood investigations: Hb%, BT, CT, Blood grouping and Rh typing.

Blood sugar, blood urea and serum creatinine.

Urine: albumin, sugar & microscopy.

Informed/ written consent will be obtained from each parent/

guardian before starting the study. All the patients parents/ legal

guardian are supplied with patient information sheet before taking

the consent.

All the investigations and interventions are done under the direct

guidance and supervision of our guide.

7.4 Has ethical clearances been obtained from your institution in case

of 7.3

YES, Ethical clearance has been obtained from VIMS Institutional

Ethics committee, VIMS, Bellary.

8. LIST OF REFERENCES

1. Neil Hopkins, Andrew Dyson. Fibreoptic intubation. Cambridge university. Nov

2000.

2. Cormack RS, Lehane J. Difficult intubation in obstetrics. Anaesthesia

1984;39:1105-11.

3. Ronald D Miller. Miller’s Anaesthesia 2005;6:2545-48.

4. Royal Adelaide hospital intensive care unit medical annual 2001 edition.

5. Ovassapian A. Fibreoptic tracheal intubation in adults.In: Ovassapian A, ed.

Fiberoptic endoscope and the difficult airway. Philadelphia: Lippincott-Raven

1996.

6. Stockhouse RA. Fiberoptic airway management. Anaesthesiology Clin North Am

2002;20:930-951.

7. Wilson ME, Speiegelhalter D, Robertson JA, Lesser P. Predicting difficult

intubation . British Journal of Anaesthesia 1998;61:211-6.

8. Lechtzin N, Rubin HR, White PJ, et al. patient satisfaction with bronchoscopy. Am

J Respir Crit Care Med 2002;166:1326-31.

9. Lechtzin N, Rubin HR, Jencker M, et al. Predictors of pain control in patients

undergoing flexible bronchoscopy. Am J Respir Crit Care Med 2000;162:440-45.

10. Ovassapian A . Flexible bronchoscopic intubation in awake patients. J

Bronchoscopy. 1994;1:240-5.

11. Chambers WA. Difficult airways-difficult decisions: guidelines for publication?

Anaesthesia 2004;59:631-3.

12. Delaney KA, Hessler R. Emergency flexible fiberoptic nasotracheal intubation. A

report of 60 cases. Am J Emerg Med 1988;17:919-6

13. Benumoff JL. Management of the difficult airway. With special emphasis on

awake tracheal intubation. Anesthesiology 1991;75:1087-110.

14. Boisson-Bertrand D, Bourgain JL, Camboulives J, et al. Difficult intubation.

French Society of Anesthesia and Intensive Care. A collective expertise. Ann Fr

Anesth Reanim 1996;15:207-14.

15. Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic

intubation. Reg Anesth Pain Med 2002;27:180-92.

16. Crawford M, Pollock J, Anderson K. Comparison of midazolam with propofol for

sedation in outpatient bronchoscopy. Br J Anaesth 1993;70:419-22.

17. Puchner W, Egger P, Purhinger F. Evaluation of remifentanil as single drug for

awake fiberoptic untubation . Acta Anaesthesiol Scand 2001;46:350-4.

18. Adachi YU, Sutomoto M, Higuchi H. Fentanyl attenuates the haemodynamic

response to endotracheal intubation more than the response to laryngoscopy.

Anesth Analg 2002;95:223-7.

19. Randell T, Valli H, Lindgren L. Effects of alfentanil on responses to awake

fiberoptic nasotracheal intubation. Acta Anaesthsiol Scand 1990;34:59-62.

20. Stoelting RK. Attenuation of blood pressure response to laryngoscope and tracheal

intubation with sodium nitroprusside. Anesth Analg 1979;58:116-9.

21. Stoelting RK. Circulatory changes during direct laryngoscope and tracheal

intubation: influence of duration of laryngoscope with or without prior lidocaine.

Anesthesiology 1977;47:381-3.

22. Prys-Roberts C, Greene LT, Meloche R Foex P. Studies of Anaesthesia in relation

to hypertension. II. Haemodynamic consequences of induction and endotracheal

intubation. Br J Anaesth 1971;43:53-8.

9. SIGNATURE OF THE

CANDIDATE

10. REMARKS OF THE GUIDE THE STUDY IS EXPECTED TO BENEFIT AIRWAY MANAGEMENT OF DIFFICULT AIRWAY CONDITIONS AND PREVENTING AVOIDABLE MORBIDITY AND MORTALITY.

11. NAME & DESIGNATION (IN

BLOCK LETTERS)

11.1 GUIDE DR. A.SRINIVAS MURTHY. M.D.

PROFESSOR & HOD

DEPT.OF.ANAESTHESIOLOGY

VIMS, BELLARY

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE

DEPARTMENT

DR. A.SRINIVAS MURTHY. M.D.

PROF. & HEAD OF DEPARTMENT

ANAESTHESIOLOGY

VIMS, BELLARY

11.6 SIGNATURE

12. 12.1 REMARKS OF THE

CHAIRMAN & PRINCIPAL

12.2 SIGNATURE