Feasibility of ProVu™ Video Stylet for awake intubation of patients with severe obesity: A pilot observational study

Background: Airway management in the obese patient is known to be challenging as oxygenation may rapidly decrease after general anesthesia induction. Mask ventilation and tracheal intubation can be complicated due to obesity-related anatomical features. The reduced safe apnea time can put the patient at risk of severe and rapid desaturation. Recent guidelines recommend avoiding the suppression of spontaneous breathing in cases of predicted anatomically or physiologically difficult airway. Many different devices, such as video stylets and video laryngoscopes, have been proposed as alternatives to traditional gold standard flexible bronchoscope use for awake intubation. Aim: Our study reports the use of a new flexible ProVu™ Video Stylet (Flexicare Medical Ltd., Mountain Ash, UK) for awake intubations in 11 patients with severe obesity, who presented with at least one criterion for potentially difficult oxygenation (during ventilation and/or intubation attempts) after suppression of spontaneous breathing. Methods: In total 11 consecutive patients with severe obesity and clinical indication for an awake tracheal intubation were enrolled over a 10-months period and intubated with the ProVu™ Video Stylet. Results: All 11 tracheal intubations were successfully performed. The procedures also highlighted potential limitations to consider while using the device in an awake intubation setting. Conclusion: Despite the limitations of this small observational pilot study, our study showed that the ProVu™ Video Stylet may be a promising tool and a valid alternative for performing awake tracheal intubation in patients with severe obesity and predictors of difficult oxygenation. Future studies are needed to compare the performance of the ProVu™ Video Stylet with video laryngoscopy and flexible bronchoscopy, and to provide stronger evidence in favor or against the use of this new device. The possible availability of an alternative device, combined with the skill and confidence to use it, may provide the anesthesiologist an additional tool for managing awake intubation of at-risk airways, in accordance with recommendations from the most recent guidelines.