Scientific Letter
Improving fiberoptic intubation in the conscious patient using the new Janus mask
Mejora del procedimiento de intubación con fibra óptica y paciente despierto con la nueva máscara Janus
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Pieri, S. Sardo, C.D. Votta, G. Frau, A. Oriani, A. Zangrillo, F. Monaco" "autores" => array:7 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Pieri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Sardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C.D." "apellidos" => "Votta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Frau" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Oriani" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Zangrillo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:4 [ "nombre" => "F." "apellidos" => "Monaco" "email" => array:1 [ 0 => "monaco.fabrizio@hsr.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">?</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Medical Sciences “M. Aresu”, University of Cagliari, Cagliari, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Vita-Salute San Raffaele University, Milan, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "?" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mejora del procedimiento de intubación con fibra óptica y paciente despierto con la nueva máscara Janus" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Fiberoptic intubation is a mainstay of predicted difficult airway management and still represents the gold standard in this clinical setting.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> The acquisition of basic skills and the improvement of dexterity in this setting may be based on clinical practice (e.g. fiberoptic intubation in ordinary airway management), simulation on mannequins, virtual bronchoscopy software, and with the inexpensive Gil 5-Minute Dexterity Model.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, some issues may arise during fiberoptic intubation even for the most trained anesthesiologists in the setting of cardiorespiratory comorbidity determining hypoxemia and need for respiratory support during the procedure.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Janus mask (Biomedical S.r.l., Florence, Italy) is a novel full-face mask designed to provide continuous positive airway pressure (CPAP) that allows to perform different endoscopic techniques such as transesophageal echocardiography, upper digestive endoscopy, and fiberoptic bronchoscopy.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3,4</span></a> This mask, indeed, is made up of two separable halves with a midline port that allows the insertion of endoscopic probes into patient's mouth or nose for diagnostic and/or therapeutic aims without interrupting the CPAP support. For this reason, it can be placed on and/or removed from patient's face even when the endoscopic examination is ongoing.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The unique features of this device may be, in our opinion, extremely useful in the management of a difficult intubation scenario.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore, we started to use it in this context and we report our experience with the first two patients treated. Both patients signed an informed consent for management and publication of data and images.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 77-year-old woman was scheduled for aortic valve replacement because of severe aortic stenosis and the preoperative anesthesiological evaluation was suggestive for a possible difficult airway, as the patient was overweight (BMI 31.2 kg/m<span class="elsevierStyleSup">2</span>), presented a Mallampati score of 3, a thyromental distance of 2.5<span class="elsevierStyleHsp" style=""></span>cm, and mouth opening was 3<span class="elsevierStyleHsp" style=""></span>cm. Furthermore, she referred history of difficult endotracheal intubation during two previous surgeries.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We planned elective intubation under fiberoptic guide and we administrated midazolam 5<span class="elsevierStyleHsp" style=""></span>mg i.v. to reduce patient's anxiety and discomfort associated with awake intubation under fiberoptic guidance, and to maintain at the same time spontaneous breathing and collaboration for simple commands, such as coughing and breathing.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Baseline SpO2 was 97% in room air, and respiratory rate was 16 breaths/min.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We delivered CPAP (PEEP 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O) plus a pressure support of 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O through the new full-face “Janus” mask in order to support ventilation and maintain oxygenation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After obtaining an Observer's Assessment of Alertness/Sedation scale score of 4 (lethargic response to name spoken in normal tone),<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> an inexperienced anesthesiologist under expert supervision performed the procedure inserting the fiberoptic probe together with the endotracheal tube through the Janus mask central port into patient's mouth. The procedure was successful and uneventful, but required three attempts and lasted 12<span class="elsevierStyleHsp" style=""></span>min.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The Janus mask was then removed simply separating its two halves, without compromising in any way the correct position and depth of the endotracheal tube. We then administered fentanyl (250<span class="elsevierStyleHsp" style=""></span>mcg), propofol (150<span class="elsevierStyleHsp" style=""></span>mg) and rocuronium (50<span class="elsevierStyleHsp" style=""></span>mg), and set the mechanical ventilation for volume control continuous mechanical ventilation. Anesthesiological management and surgery were performed as usual and no complications were recorded. The procedure is also shown as a video in the supplementary material.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0060" class="elsevierStylePara elsevierViewall">Two weeks later we treated another patient, a 69 year-old woman scheduled for thoracoabdominal aortic aneurysm repair surgery, with the same approach. On physical examination, the patient was overweight (BMI 33 kg/m<span class="elsevierStyleSup">2</span>) and displayed a Mallampati score of 3, an interincisive distance of 4<span class="elsevierStyleHsp" style=""></span>cm, loose inferior incisors, mandibular prognathism, and a reduced cervical spine range of motion. We programmed a Janus mask-aided elective awake fiberoptic intubation to manage this predicted difficult airway scenario. Baseline SpO2 was 98% in room air, and respiratory rate was 15 acts/min.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient received topical lidocaine, i.v. midazolam 2<span class="elsevierStyleHsp" style=""></span>mg to reduce the discomfort associated with the procedure, and CPAP ventilation was started. An expert anesthesiologist performed the procedure in 5<span class="elsevierStyleHsp" style=""></span>min. After the orotracheal intubation was successfully accomplished and confirmed, we induced general anesthesia with propofol i.v. 100<span class="elsevierStyleHsp" style=""></span>mg, fentanyl 150<span class="elsevierStyleHsp" style=""></span>mcg i.v., rocuronium 40<span class="elsevierStyleHsp" style=""></span>mg i.v. The surgical operation was performed as planned.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We reported a new strategy to approach one of the worst scenarios that anesthesiologists may face, that is to say, the “planned difficult intubation” situation. Such strategy can also be extended to all the intensive care unit (ICU) patients and all acute critically ill patients, who are not intubated, need to undergo endoscopic procedures (fibroscopy, transesophageal echocardiography, etc.), and present nevertheless a reduced respiratory reserve or respiratory failure.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6,7</span></a> In critically ill patients the intubation maneuver is hazardous due to factors related to the patients (hemodynamic instability, decreased oxygen and physiologic reserve, full stomach, coagulopathy, low platelet count, anticoagulants) and factors associated to the setting itself (inability of head extension, environment, attending physicians with variable levels of expertise in difficult intubation). Therefore the incidence of difficult intubation and the severity of desaturation is higher in ICU compared to the operating room.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> As a more profound desaturation is associated with higher risk of cardiac arrest,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> devices able to “gain time” during challenging intubation may improve outcome.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Janus mask applied during difficult airway management can significantly improve both pre-oxygenation and oxygenation during fibroscopic intubation maintaining an adequate oxygen saturation even in the event of prolonged or complex maneuvers. Although the pre-oxygenation is essential to avoid desaturation in the operating room, several authors have shown that it is not effective in ICU patients due to the coexistence of pulmonary and cardiac diseases, anemia, low cardiac output syndrome, sepsis, ventilation/perfusion mismatch, acute respiratory distress syndrome, pathologic states associated with increased consumption of oxygen.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10,11</span></a> The rationale of the use of the Janus mask is supported also by the data from Miguel-Montanes,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> who observed a higher saturation at the end of pre-oxygenation in critical ill patients with mild to moderate respiratory failure with the use of a high flow nasal cannula oxygen (HFNO) compared to a non-rebreathing facemask. Several differences between HFNO and Janus mask have to be addressed: first, HFNO improves oxygenation “washing out” the pharyngeal deadspace with high oxygen concentration and a modest PEEP effect, while with Janus mask can be adopted increasing the end expiratory lung volume. Then, HFNO was not superior to facemask in improving oxygenation in patient with severe hypoxia who needed intubation,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> while Janus mask maintained an adequate oxygenation in fragile patients undergoing prolonged TEE for appendage closure, procedure which required more than an hour. Finally, although there is no experience with HFNO and fibroscopy in the context of difficult intubation, the possibility to perform the CPAP with Janus mask may maintain a better gas exchange during the entire procedure.</p><p id="par0085" class="elsevierStylePara elsevierViewall">For all the reasons mentioned above we believe that the critical ill patients who may benefit from the use of this device are several in everyday clinical intensive care practice.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In addiction, the Janus mask may have a role in the training of junior colleagues with endoscopic maneuvers, as it supports ventilation and maintain oxygenation during the procedure. Therefore, long maneuvers can be tolerated, avoiding desaturation episodes.</p><p id="par0095" class="elsevierStylePara elsevierViewall">We are aware that nowadays many simulation technologies are available and allow the acquisition of basic skills about fiberoptic intubation in a safe non-clinical scenario. However, the simulation is not fully representative of the real clinical life, which is often more complicated and stressful.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Furthermore, the Janus mask can be applied also during the endoscopy in case of oversedation or respiratory worsening of the patient, as it can be opened and then closed around the probe.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Other strategies do exist to perform intubation in a planned or unplanned difficult airway scenario and were reported in literature: overall, they involve the use of existing devices (laryngeal mask, videolaringoscopes, etc.) or tracheal puncture.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14–18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Teteura and colleagues, for example, sperimented successfully Intubation Using a Double-lumen Tube with a Combination of Fiberoptic Bronchoscope and the Glidescope in a Patient with difficult airway,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> but this technique required the contemporary presence of 4 anesthesiologists, which is not generally possible in routine clinical practice (especially if the difficult airway situation is unexpected).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Furthermore, intubation with a videolaryngoscope requires a deep level of sedation, and eventually the administration of a neuromuscular blocking agents. Our strategy, on the contrary, can be performed also without curarization and with a mild/moderate level of sedation.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The I-gel laryngeal mask also proved to be a useful tool, when used in combination with a lightwand<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> or the Aintree intubation catheter.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Tracheal puncture at the level of the chricothyroid membrane to perform retrograde intubation<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> and the use of a tracheal introducer<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> were also reported as useful strategies in this context, but they are highly invasive.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our opinion the use of such invasive approaches cannot be encouraged, now that modern, non-invasive, and safe devices such as the Janus mask are available. Furthermore, none of the previously reported strategies is able to support the spontaneous ventilation with a positive pressure during intubation maneuver.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion, we believe that the Janus mask may have an extraordinary potential in clinical practice. In particular, the use of this device has a strong rational as a bridge to awake fiberoptic intubation, as a rescue ventilator therapy during interventional procedures, and as an educational tool for the anesthesiologists without experience in fiberoptic intubation, who can improve their confidence with this procedure in a safe real life scenario.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Contribution of the authors</span><p id="par0140" class="elsevierStylePara elsevierViewall">MP: collection, analysis and interpretation of data, writing of the manuscript and final revision.</p><p id="par0145" class="elsevierStylePara elsevierViewall">SS: study design, collection of data, writing of the manuscript and final revision.</p><p id="par0150" class="elsevierStylePara elsevierViewall">CVD: study design, collection of data, writing of the manuscript and final revision.</p><p id="par0155" class="elsevierStylePara elsevierViewall">GF: collection, analysis and interpretation of data, final revision of the manuscript.</p><p id="par0160" class="elsevierStylePara elsevierViewall">AO: analysis and interpretation of data, final revision of the manuscript.</p><p id="par0165" class="elsevierStylePara elsevierViewall">AZ: study design, collection and interpretation of data, final revision of the manuscript.</p><p id="par0170" class="elsevierStylePara elsevierViewall">FM: study design, collection, analysis and interpretation of data, final revision of the manuscript.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest and funding sources</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest concerning the publication of this manuscript. The study was supported by departmental funds. 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| año/Mes | Html | Total | |
|---|---|---|---|
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| 2023 Marzo | 137 | 37 | 174 |
| 2023 Febrero | 136 | 39 | 175 |
| 2023 Enero | 104 | 20 | 124 |
| 2022 Diciembre | 135 | 70 | 205 |
| 2022 Noviembre | 121 | 42 | 163 |
| 2022 Octubre | 137 | 52 | 189 |
| 2022 Septiembre | 110 | 44 | 154 |
| 2022 Agosto | 71 | 47 | 118 |
| 2022 Julio | 66 | 66 | 132 |
| 2022 Junio | 71 | 32 | 103 |
| 2022 Mayo | 77 | 42 | 119 |
| 2022 Abril | 51 | 48 | 99 |
| 2022 Marzo | 87 | 61 | 148 |
| 2022 Febrero | 58 | 30 | 88 |
| 2022 Enero | 68 | 64 | 132 |
| 2021 Diciembre | 53 | 49 | 102 |
| 2021 Noviembre | 63 | 48 | 111 |
| 2021 Octubre | 77 | 87 | 164 |
| 2021 Septiembre | 43 | 39 | 82 |
| 2021 Agosto | 55 | 44 | 99 |
| 2021 Julio | 36 | 37 | 73 |
| 2021 Junio | 62 | 39 | 101 |
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| 2021 Enero | 71 | 18 | 89 |
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| 2020 Noviembre | 54 | 28 | 82 |
| 2020 Octubre | 60 | 37 | 97 |
| 2020 Septiembre | 62 | 23 | 85 |
| 2020 Agosto | 39 | 19 | 58 |
| 2020 Julio | 46 | 28 | 74 |
| 2020 Junio | 36 | 16 | 52 |
| 2020 Mayo | 42 | 23 | 65 |
| 2020 Abril | 41 | 15 | 56 |
| 2020 Marzo | 16 | 18 | 34 |
| 2020 Febrero | 79 | 45 | 124 |
| 2020 Enero | 33 | 38 | 71 |
| 2019 Diciembre | 33 | 28 | 61 |
| 2019 Noviembre | 24 | 26 | 50 |
| 2019 Octubre | 37 | 26 | 63 |
| 2019 Septiembre | 28 | 35 | 63 |
| 2019 Agosto | 37 | 24 | 61 |
| 2019 Julio | 37 | 24 | 61 |
| 2019 Junio | 29 | 16 | 45 |
| 2019 Mayo | 56 | 51 | 107 |
| 2019 Abril | 30 | 26 | 56 |
| 2019 Marzo | 39 | 32 | 71 |
| 2019 Febrero | 49 | 49 | 98 |
| 2019 Enero | 50 | 57 | 107 |
| 2018 Diciembre | 60 | 56 | 116 |
| 2018 Noviembre | 146 | 118 | 264 |
| 2018 Octubre | 152 | 42 | 194 |
| 2018 Septiembre | 69 | 20 | 89 |
| 2018 Agosto | 47 | 32 | 79 |
| 2018 Julio | 35 | 24 | 59 |
| 2018 Junio | 51 | 19 | 70 |
| 2018 Mayo | 1 | 0 | 1 |
| 2018 Abril | 14 | 4 | 18 |
| 2018 Marzo | 1 | 2 | 3 |
| 2017 Julio | 0 | 1 | 1 |
| 2017 Abril | 0 | 1 | 1 |
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