Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial

Abstract

Background

Awake fiberoptic nasotracheal intubation is usually performed in patients with an anticipated difficult airway. This study compares dexmedetomidine and remifentanil for conscious sedation during fiberoptic intubation.

Methods

Forty patients undergoing elective awake fiberoptic nasotracheal intubation were allocated randomly to receive either dexmedetomidine (n = 20) or remifentanil (n = 20). Primary outcome measures were endoscopy, intubation, and post-intubation conditions as scored by the attending anesthesiologist. Other parameters included the time taken to achieve the desired level of sedation, endoscopy time, intubation time, and hemodynamic changes during the procedure. An interview was conducted 24 h after surgery to evaluate patients’ recall of and satisfaction with the procedure.

Results

The median [interquartile range] endoscopy score (graded 0–5) in the dexmedetomidine group (2 [1–2]) was significantly better than in patients who received remifentanil (3 [2–3]; p < 0.01). Recall of intubation was significantly lower in the dexmedetomidine group (p = 0.027). Dexmedetomidine provided better patient satisfaction than remifentanil (2 [1–2] and 2 [2–3], respectively; p = 0.022). Patients in the dexmedetomidine group had fewer heart rate responses during endoscopy and intubation as compared to the remifentanil group (p < 0.001 and p = 0.004, respectively). Peripheral oxygen saturation was less in the remifentanil group during endoscopy (p = 0.003). There were no significant differences in intubation and post-intubation conditions.

Conclusions

Both dexmedetomidine and remifentanil were effective as sedatives in patients undergoing awake fiberoptic nasotracheal intubation. Compared with remifentanil, dexmedetomidine offered better endoscopy scores, lower recall of intubation, and greater patient satisfaction, with minor hemodynamic side effects.

Appendix 1

Endoscopy score 0, 1, 2, 3, 4, 5

Grimacing

Localizing

Coughing on lidocaine via scope

Coughing on entering infraglottic space

Prolonged coughing

Intubation score 0, 1, 2, 3, 4, 5

Grimacing when tube in nares

Localizing with one limb at any stage

Localizing with two limbs at any stage

Coughing on entering trachea

Prolonged coughing

Post-intubation score 1, 2, 3

1 Cooperative, obeying commands

2 Uncomfortable, GA imminent

3 Other (specify)

Postoperative interview

Amnesia

Recall of endoscopy: Yes, No

Recall of intubation: Yes, No

Adverse events

Sore throat: Yes, No

Hoarseness: Yes, No

Satisfaction score: 1, 2, 3, 4

Excellent

Good

Acceptable

Poor