Many anatomical and pathophysiological modifications are responsible for the significant challenges associated with airway management in obese patient.

The safe apnea time is ‘physiologically’ reduced.

The accumulation of adipose tissue facilitates early bronchial closure.

The frequent presence of concomitant Obstructive Sleep Apnea Syndrome (OSAS) may further compromise airway patency after anesthesia induction [[1], [2], [3]].

Recent airway management guidelines strongly recommend a multifactorial pre-procedural airway assessment, aimed at predicting any potential oxygenation difficulties during airway management [4,5]. To reduce the risk of major adverse events for the patient after spontaneous breathing suppression, awake tracheal intubation (ATI) should be considered whenever anatomical and/or physiological factors suggest oxygenation-related risk [4,5].

Maintaining adequate oxygenation in peri-operative airway management, especially in obese patients, is essential to prevent complications [6].

ATI can be effectively performed with a flexible bronchoscope (FBS) [7], video laryngoscope (VL) [8,9], or video stylet (VS) [10]. However, no clear superiority has been established among these devices in terms of safety and feasibility [11].

The ProVu™ Video Stylet (VS) is a recently introduced, new generation intubation device, which includes a dedicated tracheal tube with a softer tip and a flexible stylet indicated for difficult intubations (Fig. 1). It features a tip controlled by the operator via a bidirectional wheel, allowing flexion (tip up) and retroflexion (tip down) of the stylet and the mounted tracheal tube within a range of 100° (45° flexion and 55° retroflexion). A malleable rod allows preshaping of the tracheal tube, but can be removed if greater flexibility is needed.

The device is therefore able to be adapted to the airway, making unnecessary the alignment of the oral, pharyngeal, and tracheal axes normally required for classic laryngoscopy. A camera on the tip transmits the images to a high-resolution screen, allowing clear visualization of the intubation procedure, which can be shared with the whole team.

To date, there have been no reported cases of awake intubations with ProVu™ VS in obese patients with anticipated difficult airways. One small case series describing three awake intubations in normally weighted patients with predicted difficult airways has been published [12].

We performed a pilot study to test the feasibility of ProVu™ VS as a device facilitating awake intubation in patients with severe obesity and at least one other predictor for difficult ventilation and/or intubation.