Awake Nasal Fiberoptic Intubation in Lateral Position for Severely Obese Patients with Anticipated Difficult Airway: A Randomized Controlled Trial

Background: Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position. Methods: This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients. Results: Sixty patients with a median age of 37 [inter-quartile range (IQR): 29–44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5–50.8] kg/m(2). The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8–228.8] seconds (s) in the lateral position, compared to 214.5 [181.8–280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045). Conclusions: In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway.