A case of the unanticipated difficult airway where bougie was used as a conduit over I gel as a rescue airway for one-lung ventilation under direct vision of fiberoptic bronchoscopy

Shalendra Singh; Arijit Ray; Deepak Dwivedi; Saurabh Sud; Priya Taank

doi:10.4103/ijhas.IJHAS_38_20

CASE REPORT

Year : 2021 | Volume : 10 | Issue : 2 | Page : 173-174

A case of the unanticipated difficult airway where bougie was used as a conduit over I gel as a rescue airway for one-lung ventilation under direct vision of fiberoptic bronchoscopy

Shalendra Singh¹, Arijit Ray¹, Deepak Dwivedi², Saurabh Sud², Priya Taank³
¹ Department of Anaesthesiology and Critical care, Armed forces medical College, Pune, Maharashtra, India
² Department of Anaesthesiology and Critical care, Command Hospital, Pune, Maharashtra, India
³ Department of Ophthalmology, Command Hospital, Pune, Maharashtra, India, India<

Date of Submission	17-Jul-2020
Date of Decision	11-Oct-2020
Date of Acceptance	03-Dec-2020
Date of Web Publication	18-May-2021

Correspondence Address:
Dr. Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijhas.IJHAS_38_20

Abstract

The basic foremost step for any surgery done under general anesthesia is to place an endotracheal tube (ETT) into the trachea. Placement of a definitive airway is vital to maintain a critical level of oxygen in the end organ during apnea time. There are multiple ways revealed in the literature to place ETT into the trachea. Sometimes, placement can be achieved speedily at the critical time with the experience of anesthesiologist and availability of different airway adjutants. Here, we describe a case of ETT intubation using bougie as a conduit over I gel under direct vision of fiberoptic bronchoscopy in a thymic enhancing mass.

Keywords: Difficult airway, general anesthesia, one lung ventilation

How to cite this article:
Singh S, Ray A, Dwivedi D, Sud S, Taank P. A case of the unanticipated difficult airway where bougie was used as a conduit over I gel as a rescue airway for one-lung ventilation under direct vision of fiberoptic bronchoscopy. Int J Health Allied Sci 2021;10:173-4

How to cite this URL:
Singh S, Ray A, Dwivedi D, Sud S, Taank P. A case of the unanticipated difficult airway where bougie was used as a conduit over I gel as a rescue airway for one-lung ventilation under direct vision of fiberoptic bronchoscopy. Int J Health Allied Sci [serial online] 2021 [cited 2023 Dec 11];10:173-4. Available from: https://www.ijhas.in/text.asp?2021/10/2/173/316295

Introduction

Endotracheal intubation is the basic foremost step for any surgery done under general anesthesia. It is tremendously vital to speedily and unfussy place endotracheal tube (ETT) into the trachea for their critical maintenance of oxygen level. Diverse techniques have been advocated in the literature to place ETT into the trachea. The placement of ETT can be achieved with the experience of the anesthesiologist and the availability of adjutants for safe anesthesia. Various supraglottic airways are described as a conduit for tracheal intubation.^[1],[2] ETT over I gel already been described in the literature but the use of a univent tube for one-lung ventilation (OLV) is not described.^[3]

Case Report

A male patient of age 44 years, 64 Kg weight, and 158 cm height (body mass index 25.6 Kg/m²) presented with drooling of the eyelid for 1 month. He was diagnosed to have 6.3 cm × 4.7 cm × 1.6 cm thymic enhancing mass in anterior meditational. Routine airway examination was unremarkable. The patient was accepted in ASA physical status II. All standard monitoring was attached and the patient was premedicated with glycopyrrolate 0.2 mg, midazolam 1 mg, and 100 μg of fentanyl and induced with 2 mg/kg of propofol. After determining that mask ventilation was easy, he was given 30 mg of atracurium for muscle relaxation. The patient was attempted three times with direct laryngoscopy using Macintosh size 3 and 4 blades without being able to visualize the larynx. However, meantime able to ventilate with mild difficulty and I gel size 4 was inserted. A fiberoptic bronchoscope was then inserted through the I gel and the vocal cords appeared to be edematous. Under the direct fiberoptic vision, a gum elastic bougie was passed through the vocal cords, I gel and fiberoptic bronchoscope removed and a 6.5-mm cuffed univent tube roaded on gum elastic bougie into the trachea [Figure 1]. Correct tube placement was confirmed by 5-point auscultation and capnography. The patient underwent left transthoracic thymectomy with 4^th rib cutting. Anesthesia was maintained with O2: N2O, sevoflurane and an intermittent dose of muscle relaxant. He remained hemodynamically stable throughout the surgery. Two liters of crystalloid were infused intraoperatively with a total blood loss of 350 ml. The bronchial blocker cuff deflated and bilateral lung ventilation continued at the end. The patient was shifted to the surgical intensive care unit (SICU) with ETT in situ and was kept on spontaneous ventilatory support in view of difficult airway and risk of airway edema. After 12 h, the patient was extubated uneventfully in SICU on an airway exchange catheter in view of potential difficult extubation.

Figure 1: Bougie seen by fiberoptic bronchoscopy over I gel into vocal cord

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Discussion

In a review article in failed intubation scenarios, various supraglottic airways are described as a conduit for tracheal intubation.^[1],[2] ETT over I gel already been described in the literature but the use of a univent tube for OLV is not described.^[3] Airway management of patients presenting for OLV is a challenging task for the anesthesiologist, as acute loss of the airway during interventions can result in morbidity and mortality. Secured the patient's airway with a univent tube after muscle relaxant sometimes land into loss of airway. Anesthesiologist also faces difficulty to insert the tip of the univent tube into the vocal cord with manipulation. However, I gel is well known to be used when difficult in the inserting tube faced.^[4] There is no consensus in the literature regarding airway management in this situation. Lateran to facilitate OLV, bougie under fiberoptic bronchoscope guidance can be used.^[5] Once the patient's trachea was intubated, lung separation was achieved with a univent tube. We do it as a standard of practice at our institute for all difficult airway cases. We did not prefer cricothyroidotomy as it can lead to serious morbidity, including can't ventilate-can't intubate “CVCI” scenarios necessitating emergency surgical airways, and death. Anesthesiologist's vigilance and judgment only help him to tide over the situations of a difficult airway. Therefore, all anesthesiologists should be well versed to deal with such situations.

Declaration of patient consent

The patient's course was not fatal and his identity not identified. The approval for publication of the manuscript came from the Department of Anaesthesiology and Critical Care at the Armed Forces Medical College Pune. Patient's names and initials are not published and due efforts are 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

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