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GENERAL ARTICLES

Propofol Without Muscle Relaxants for Conventional or Fiberoptic Nasotracheal Intubation: A Dose-Finding Study

Harald Andel, MD^*, Gerhard Klune, MD^*, Dorothea Andel, MD^*, Michael Felfernig, MD^*, Andrew Donner, MD^*, Wolfgang Schramm, MD^*, and Michael Zimpfer, MD^*,

*Department of Anesthesia and Intensive Care, University of Vienna; and Ludwig-Boltzmann-Institute for Anesthesiology and Intensive Care, Vienna, Austria

Address correspondence and reprint requests to Harald Andel, MD, AKH-Vienna, Department of Anesthesia and Intensive Care, Waehringer Guertel 18–20, 1090 Vienna, Austria. Address e-mail to harald.andel{at}akh-wien.ac.at

Endotracheal intubation has been performed during the administration of propofol anesthesia without neuromuscular blockade. In this study, we determined the propofol dose required for conventional nasotracheal or for fiberoptic nasotracheal intubation of all patients. Thirty-two patients undergoing maxillofacial surgery were randomly assigned to the conventional (n = 16) or to the fiberoptic (n = 16) intubation group. In both groups, anesthesia was induced by using IV fentanyl and IV titrated propofol according to clinical need (spontaneous respiration rate, verbal response). An endotracheal tube was placed nasally in the pharynx and the vocal cords visualized by using a fiberscope inserted via the tube. In the conventional group, the larynx was visualized additionally with a laryngoscope blade (Miller). In both groups propofol was titrated until the vocal cords opened. Patients were tracheally intubated, and the propofol dose was recorded. In all patients, the trachea could be intubated without the use of muscle relaxants. Considerable interindividual differences of dose requirements were observed. The amount of propofol required in the conventional group was significantly (P < 0.0001) larger (median ± SD: 2.74 ± 1.59 mg/kg; range 1.95–7.07 mg/kg) than in the fiberoptic group (1.37 ± 0.59 mg/kg; 0.72–2.86 mg/kg). Hemodynamics remained stable in all patients. Postintubational hoarseness occurred in three patients of each group. Fiberoptic nasal intubation without a muscle relaxant can be facilitated with significantly smaller and more predictable dosages of propofol than conventional nasal endotracheal intubation. The possibility of titrating the propofol dose under assisted ventilation until the vocal cords open during fiberoptic nasotracheal intubation and the better predictability of the required dose favors the fiberoptic approach.

Implications: In this study, contrary to all preceding studies using predefined doses of propofol and opioids, we determined the minimal required propofol dose in combination with fentanyl for conventional or fiberoptic nasotracheal intubation without muscle relaxants.

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