|Year : 2017 | Volume
| Issue : 2 | Page : 123-126
Awake fiberoptic nasal intubation in a patient scheduled for commando's operation
Arnab Paul, Aparajita Nathroy
Department of Anaesthesiology, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India
|Date of Web Publication||18-May-2017|
Department of Anaesthesiology, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Fiberoptically guided tracheal intubation represents one of the most important advances in airway management occurring in the past 30 years. Perhaps, its most important role is the management of the anticipated difficult airway. Out of the available airway devices from the basic Macintosh laryngoscope to video laryngoscopes to the life-saving surgical airway techniques, fiberoptic-guided intubation still remains to be the most successful method in experienced hands during handling of difficult airway. We report a case of fiberoptic-guided successful nasal intubation in a spontaneously breathing awake patient under topical anesthesia with an anticipated difficult airway scheduled for commando's operation.
Keywords: Awake nasal intubation, commando operation, difficult airway, fiberoptic bronchoscope
|How to cite this article:|
Paul A, Nathroy A. Awake fiberoptic nasal intubation in a patient scheduled for commando's operation. Int J Health Allied Sci 2017;6:123-6
|How to cite this URL:|
Paul A, Nathroy A. Awake fiberoptic nasal intubation in a patient scheduled for commando's operation. Int J Health Allied Sci [serial online] 2017 [cited 2020 Mar 29];6:123-6. Available from: http://www.ijhas.in/text.asp?2017/6/2/123/206418
| Introduction|| |
Awake fiberoptic intubation is an essential skill in the management of a patient with a known difficult airway or who has an anticipated difficult airway. It is a technique which allows oral or nasal route to provide a clear visualization of the vocal cords and subsequent passage of an endotracheal tube (ETT) into the trachea under direct vision. According to American Society of Anesthesiologist difficult airway algorithm, awake intubation devices used in the recent past include direct laryngoscopy and intubation, blind nasal/oral intubation, fiberoptic intubation, intubating laryngeal mask airway-assisted intubation, trachlight intubation, and retrograde intubation or percutaneous dilatation tracheostomy. Out of these, awake fiberoptic intubation remains the safest and most effective methods in the experienced hands.,
We report a case of fiberoptic-guided nasal intubation in a spontaneously breathing awake patient under topical anesthesia with an anticipated difficult airway scheduled for commando's operation.
| Case Report|| |
A 45-year-old male patient weighing 62 kg presented with the complaint of progressively increasing swelling involving the left side of his cheek for 9 months and also had difficulty in opening of the mouth for 2 months. Due to his inability to open the mouth, he was on liquid diet for the last 2 months. He was chronic tobacco chewer and had left tobacco chewing for the last 8 months. He was diagnosed as carcinoma buccal mucosa left side and was posted for commando operation under general anesthesia.
On general examination, the patient was found to be afebrile, pulse rate 86/min, blood pressure (BP) 130/76 mmHg, respiratory rate 16/min. Pallor was present and submandibular lymph nodes were palpable. On airway examination, difficult airway was anticipated due to restricted mouth opening (less than one finger) and Grade IV Mallampati score [Figure 1]. Oral cavity revealed bad oral hygiene. Sternomental and thyromental distances were 12.5 cm and 6.5 cm, respectively. Systemic examination and preoperative routine laboratory investigations were within normal limits except Hb which was 9.2 gm%. Electrocardiogram (ECG) and chest X-ray showed no abnormality. X-ray neck detected no deviation of the trachea. Informed written consent for the procedure and publication was taken before surgery.
On the day of surgery, difficult airway trolley and standby arrangement for emergency tracheostomy were kept ready. Monitors such as pulse oximeter, noninvasive BP, ECG, end-tidal carbon dioxide (ETCO2), and temperature were connected. An intravenous line was secured with 18-gauge intracath. The patient was catheterized. The patient was premedicated with injection glycopyrrolate (0.2 mg), injection midazolam (1 mg), and injection fentanyl (25 μg) intravenously. For nasal decongestion and anesthesia, xylometazoline 0.05% nasal drops (2–3 drops) were applied to each nostril, and then, cotton-tipped buds soaked in 4% lignocaine are passed along the floor of the nose. Tip of the tongue is sprayed once with 10% lignocaine spray. The tongue is extruded and held by the operator and the oropharynx was sprayed four times with the 10% spray. Bilateral superior laryngeal nerve block was done 1 cm below the greater cornu of hyoid with 2 ml of 2% lignocaine without adrenaline and recurrent laryngeal nerve block was done by injecting 2 ml of the same anesthetic after piercing cricothyroid membrane. Both nasal passages were lubricated with lubricant jelly and fiberoptic bronchoscope was passed through the left nasal passage. After manipulation, glottis was visualized and bronchoscope was held above larynx [Figure 2]. Then, Portex cuffed endotracheal tube number 7.5 was introduced though the right nasal passage. Awake endotracheal intubation was done successfully by direct visualization of the vocal cord by the bronchoscope which was held just above the larynx. Position of the tube was confirmed by ETCO2. The patient was induced with injection propofol 120 mg and anesthesia was maintained on O2, N2O, isoflurane, and injection vecuronium [Figure 3]. Intraoperative period was uneventful. 1500 ml of crystalloid and 400 ml of colloid were infused intraoperatively. Total blood loss was 300 ml and urine output was 400 ml. Surgery lasted for 150 min. At the end of surgery, neuromuscular blockade was reversed with injection neostigmine (2.5 mg) and injection glycopyrrolate (0.4 mg) intravenously. The patient was shifted to surgical intensive care unit (SICU) with endotracheal tube in situ for postoperative observation. He was kept on spontaneous ventilation with oxygen supplementation through T-piece for 24 h in view of difficult airway and risk of airway edema. After 24 h, the patient was extubated uneventfully in SICU on airway exchange catheter as it was a potential difficult airway. The patient was discharged on 7th post operative day [Figure 4].
| Discussion|| |
Patients with maxillofacial, head and neck tumors pose a great challenge to an anesthesiologist for securing the airway. The incidence of difficult intubation has been shown to be higher in oral and neck cancer patients than general surgery patients. The first step for difficult airway management is to recognize it. Preanesthetic evaluation of the patient is important to reduce the morbidity and mortality related with airways management. Fiberoptic bronchoscope is known to be gold standard and has been used for awake intubation in anticipated difficult airway scenarios.
In case of anticipated difficulty in ventilation or oxygenation, awake intubation has several advantages which include maintenance of spontaneous ventilation, maintaining retropalatal space opened, and posterior placement of the larynx. It also maintains the tone of the esophageal sphincter which reduces the risk of reflux and aspiration., Moreover, if something goes wrong, spontaneous ventilation can be preserved. Brain damage, cardiorespiratory arrest, unnecessary tracheostomy, and trauma to the airways are the major complications associated with improper management of the airways and it represents the most frequent cause of mortality and morbidity in anesthesiology.
The best results for awake intubation are obtained by a combination of regional block and sedation, which decrease patient's anxiety and help him/her to tolerate the intubation maneuvers. Absolute contraindications to elective awake intubation include allergy to the local anesthetic and refusal of the patient to cooperate with the procedure. As in our case, the mouth opening was less than one finger, so we wanted to avoid the oral route for intubation and ventilation. We also did not opt for elective tracheostomy as it is associated with a number of potential morbidities and loss of natural functions such as warming, filtering, humidification of the airway, and loss of subglottic pressure which make the patient prone to infections. In this anticipated difficult airway scenario to preserve spontaneous ventilation, nasal endotracheal intubation guided by awake fiberoptic technique was the only best option. Hence, we decided to intubate the patient nasally, guided by fiberoptic bronchoscope and not by conventionally preloaded ETT maneuver. The preloaded ETT in fiberoptic bronchoscope has got some disadvantages such as resistance during placement, poor size matching of the ETT, and increased gap between ETT and the scope. This results in the leading edge of the ETT coming in contact and getting caught on glottic structures as it passes through the cords over the bronchoscope. A number of reports have focused on the mechanisms of ETT advancement during fiberoptic intubation (FOI) leading to traumatic laryngeal injury. Using in vivo endoscopic visualization of the intubation, Johnson et al. demonstrated that the structure most frequently impinged upon during attempted FOI was the right arytenoids cartilage. In addition, the greater the gap between the ETT and the bronchoscope, the higher the likelihood of failure of threading the tube. Using a smaller diameter ETT or a larger diameter bronchoscope to minimize this gap is generally recommended.
A recent study of 45 patients undergoing clinically indicated (orotracheal) FOI demonstrated that tracheal intubation on the first attempt by conventional preloaded ETT maneuver failed in 53.3% of cases, a rate similar to those reported in other studies., It has been shown that impingement of the tube on laryngeal structures decreases with the use of a modified tip such as a tapered tip  or Parker Flex-Tip  ETT. As we did not have those tubes, we used normal portex cuffed ETT. We passed the bronchoscope through one nostril and held it just above the vocal cords, and then, we introduced the proper sized endotracheal tube through other nostril. Intubation was done smoothly under direct visualization on the first attempt without any trauma to the larynx and soft tissues.
| Conclusion|| |
Awake fiberoptic-guided nasal intubation in anticipated difficult airway is the gold standard procedure for the successful management of carcinoma oral cavity. This modified technique showed smooth induction and avoided any trauma to the larynx which is quite common in conventional method where preloaded ETT is threaded over the fiberoptic bronchoscope.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khan RM. Local anesthesia and sedation regime for awake intubation. In: Khan RM, Maroof M, editors. Airway Management. Vol. 4. Hyderabad: Paras Medical Publisher; 2011. p. 147-50.
Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, et al.
A rapidly enlarging neck mass: The role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627-9.
Arné J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, et al.
Preoperative assessment for difficult intubation in general and ENT surgery: Predictive value of a clinical multivariate risk index. Br J Anaesth 1998;80:140-6.
Gupta S, Sharma R, Jain D. Airway assessment: Prediction of difficult airway. Indian J Anaesth 2005;49:257-62. [Full text]
Nandi PR, Charlesworth CH, Taylor SJ, Nunn JF, Doré CJ. Effect of general anaesthesia on the pharynx. Br J Anaesth 1991;66:157-62.
Hudgel DW, Hendricks C. Palate and hypopharynx – Sites of inspiratory narrowing of the upper airway during sleep. Am Rev Respir Dis 1988;138:1542-7.
Melhado VB, Fortuna AO. Difficult airway. In: Yamashita AM, Fortis EAF, Abrão J, Mathias LA, Cunha LB, Fáscio MN, editors. Course of distance education in anesthesiology. Sao Paulo: Office; 2004. p. 15-107.
Reed AP. Preparation for intubation of the awake patient. Mt Sinai J Med 1995;62:10-20.
Marsh NJ. Easier fiberoptic intubations. Anesthesiology 1992;76:860-1.
Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005;102:910-4.
Hakala P, Randell T. Comparison between two fibrescopes with different diameter insertion cords for fibreoptic intubation. Anaesthesia 1995;50:735-7.
Brull SJ, Wiklund R, Ferris C, Connelly NR, Ehrenwerth J, Silverman DG. Facilitation of fiberoptic orotracheal intubation with a flexible tracheal tube. Anesth Analg 1994;78:746-8.
Hakala P, Randell T, Valli H. Comparison between tracheal tubes for orotracheal fibreoptic intubation. Br J Anaesth 1999;82:135-6.
Jones HE, Pearce AC, Moore P. Fibreoptic intubation. Influence of tracheal tube tip design. Anaesthesia 1993;48:672-4.
Kristensen MS. The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: A randomized double-blind study. Anesthesiology 2003;98:354-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]