El-Boghdadly Kariem, Desai Neel, Jones Jordan B, Elghazali Sally, Ahmad Imran, Sneyd J Robert
Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.
King's College London, London, UK.
Anaesthesia. 2025 Jan;80(1):74-84. doi: 10.1111/anae.16452. Epub 2024 Oct 28.
Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta-analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation.
We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta-analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias.
In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty-one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low.
To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen.
不同的镇静方案已被用于促进清醒气管插管，但相关证据尚未得到有力整合，尤其是在临床重要结局方面。我们进行了一项系统评价和网状Meta分析，以确定最有可能与成功气管插管、较短的成功插管时间和较低的动脉血氧饱和度降低风险相关的镇静技术。
我们检索了针对任何适应证接受清醒气管插管患者的随机对照试验，并报告：总体气管插管成功率；气管插管时间；动脉血氧饱和度降低的发生率；以及其他相关结局。如果纳入的试验之间比较了两种或更多种镇静方案，我们对这些结局进行了频率学派网状Meta分析。我们还进行了敏感性分析，排除了偏倚风险高的试验。
总共纳入了48项研究，涉及2837例患者，比较了33种不同的方案。比较总体清醒气管插管成功率（38项研究，2139例患者），没有证据表明任何一种单独的镇静方案更优。比较成功气管插管的时间（24项研究，1745例患者），任何镇静策略都优于安慰剂。当我们排除偏倚风险高的试验时，我们发现没有证据表明任何干预措施在成功气管插管时间方面存在差异。31项研究（1753例患者）表明，与其他干预措施相比，右美托咪定和硫酸镁与降低动脉血氧饱和度降低的风险相关，但排除偏倚风险高的试验表明干预措施之间没有相关差异。我们每个结局的证据质量都很低。
为了最大限度地实现有效且安全的清醒气管插管，优化氧合、局部气道麻醉和操作表现可能比任何特定的镇静方案更有影响。
