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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 388-389

Awake fiber-optic intubation: A savior in difficult airway conditions


1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, India
2 Department of Anaesthesiology and Critical Care, Command Hospital (SC), Pune, India
3 Department of Pulmonary, Critical Care and Sleep Medicine, AICTS, Pune, India

Date of Submission05-May-2020
Date of Decision11-Jun-2020
Date of Acceptance20-Jul-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Dr. Saurabh Sud
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_32_20

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How to cite this article:
Singh S, Sharma R, Sud S, Paul D, Marwah V. Awake fiber-optic intubation: A savior in difficult airway conditions. Int J Health Allied Sci 2020;9:388-9

How to cite this URL:
Singh S, Sharma R, Sud S, Paul D, Marwah V. Awake fiber-optic intubation: A savior in difficult airway conditions. Int J Health Allied Sci [serial online] 2020 [cited 2020 Oct 21];9:388-9. Available from: https://www.ijhas.in/text.asp?2020/9/4/388/298118



Sir,

In the present era, the awake fiber-optic intubation (AFOI) has been overshadowed with the advent of newer ventilating and intubating modalities such as supraglottic airway devices, video laryngoscope, lighted stylet, and Trachway for management of the difficult airway.[1] Ahmad and Bailey had shown Trachway to be superior to AFOI in patients with <3 cm mouth opening.[1] However, the fact remains that AFOI is still the gold standard for the management of predicted difficult airway.[2] We report a case of acute suppurative lymphadenitis of the neck with nil mouth opening in a geriatric patient where AFOI helped anesthesiologist in securing the airway.

We present a 92-year-old male with body mass index of 18.3 kg/m2, a case of acute suppurative lymphadenitis neck who was scheduled for surgical incision and drainage under general anesthesia at our hospital. History suggested that dental extraction 4 weeks back was followed by swelling and pain over the lower part of the face and upper part of the neck. Preanesthesia assessment showed zero mouth opening; electrocardiogram revealed irregular rhythm with ventricular premature complexes, and echocardiography showed mild tricuspid regurgitation and aortic regurgitation. Preoperative computed tomography showed swelling neck extended superiorly till the right parotid gland, medially displacing the thyroid gland and extended and displaced the major neck vessels inferiorly [Figure 1]. The patient was accepted in the American Society of Anesthesiologists (ASA) physical status III. In preoperating room, neubalization with 2 ml of 2% lignocaine, insertion of nasal drops of 0.1% xylometazoline, and injection (inj) glycopyrrolate 0.2 mg intravenous (IV) and inj hydrocortisone 100 mg IV were administered. The ASA standard monitoring ensured and difficult airway cart was kept ready in the operation theater. Sedation was achieved with dexmedetomidine IV infusion (titrated dose between 0.2 and 0.5 μg/kg) without the loading dose. The airway was anesthetized via the “Spray As You Go”technique by injecting 3 ml of 4% lignocaine through the bronchoscope, and the airway was secured with 7.0 mm ID cuffed flexo-metallic endotracheal tube (nasal). Ventilation was confirmed by the presence of breath sounds and end-tidal carbon dioxide. The patient was co-induced with inj fentanyl 70 μg and inj propofol 70 mg IV. Muscle relaxation was achieved by Inj atracurium 25 mg IV and anesthesia was maintained by oxygen/nitrous/sevoflurane. The intraoperative course was uneventful. The patient was not reversed and shifted to the intensive care unit for elective mechanical ventilation in lieu of difficult airway. The patient was extubated after 24 h and discharged to home after 5 days.
Figure 1: Computed tomography image of the neck showing swelling displacing the thyroid gland and the major neck vessels

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Airway management of patients with deep neck infection presenting for surgical drainage is a challenging task for the anesthesiologist, as acute loss of the airway during interventions can result in morbidity and mortality.[3] There is no consensus in the literature regarding airway management in this situation. The popularly practiced methods are conventional laryngoscopy and intubation, tracheostomy, awake blind nasal intubation, and AFOI. Classically tracheostomy is considered as the standard of care for the establishment of a definite airway.[4] We want to bring into your notice that in this type of scenario, it is always customary to take the informed and written consent for tracheostomy too. We do it as a standard of practice at our institute for all difficult airway cases. Distorted anatomy of the airway, edema, and tissue immobility makes orotracheal intubation with rigid laryngoscopy difficult.[4] Blind nasal intubation was not attempted in our case, as repeated attempts would have caused increased trauma and could have precipitate complete airway closure leading to “cannot ventilate cannot intubate”(CVCI) situation. Laryngoscopy and intubation were not considered in our case, as the patient had zero mouth opening. Blind nasal intubation under topical anesthesia may provide an alternative safe method in cases of anticipated difficult intubation, particularly if fiber-optic bronchoscope is not available or failed to pass through the glottis, as the view is obscured by blood and/or secretions.[5]

We did not prefer fiber-optic intubation after deep sedation/muscle relaxant, as it can lead to serious morbidity, including “CVCI”scenarios necessitating emergency surgical airways, and death. We omitted the loading dose of dexmedetomidine to avoid deep sedation and undesirable haemodynamic effects. We aimed to achieve mild sedation and to alleviate the anxiety level of the patient so that he cooperates for AFOI. Anesthesiologist's vigilance and judgment only help him to tide over the situations of a difficult airway. Edema, distorted anatomy, and secretions make AFOI difficult, but regular practice and skill make the procedure easy and successful. Therefore, all anesthesiologists should be well versed with the AFOI technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands 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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahmad I, Bailey CR. Time to abandon awake fibreoptic intubation? Anaesthesia 2016;71:12-6.  Back to cited text no. 1
    
2.
Rajan S, Talukdar R, Tosh P, Paul J, Vasu BK, Kumar L. Hemodynamic responses and safety of sedation following premedication with dexmedetomidine and fentanyl during fiberoptic-assisted intubation in patients with predicted difficult airway. Anesth Essays Res 2018;12:11-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: A case series and review of the literature. Anesth Analg 2005;100:585-9.  Back to cited text no. 3
    
4.
Mishra N, Singh S. A case of fiberoptic bronchoscopy used as innovative aid for life saving in difficult surgical tracheostomy patient. Korean J Anesthesiol 2019;72:620-1.  Back to cited text no. 4
    
5.
Yoo H, Choi JM, Jo JY, Lee S, Jeong SM. Blind nasal intubation as an alternative to difficult intubation approaches. J Dent Anesth Pain Med 2015;15:181-4.  Back to cited text no. 5
    


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