Fibreoptic intubation in an adult with restricted mouth opening facilitated by improvised bite block from the barrel of syringe

Prem Raj Singh; Tanmay Tiwari; Vaibhav Tewari; Gyan Prakash Singh

doi:10.4103/ARWY.ARWY_22_19

CASE REPORT

Year : 2019 | Volume : 2 | Issue : 3 | Page : 151-153

Fibreoptic intubation in an adult with restricted mouth opening facilitated by improvised bite block from the barrel of syringe

Prem Raj Singh, Tanmay Tiwari, Vaibhav Tewari, Gyan Prakash Singh
Department of Anaesthesiology and Critical Care, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission	10-Jul-2019
Date of Acceptance	13-Sep-2019
Date of Web Publication	30-Jan-2020

Correspondence Address:
Dr. Vaibhav Tewari
Department of Anaesthesiology and Critical Care, King George's Medical University, Lucknow - 226 023, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_22_19

Abstract

Fibreoptic intubation is an effective technique for establishing airway access in patients with both anticipated and unanticipated difficult airways. First described in the late 1960s, this approach can facilitate airway management in a variety of clinical scenarios given proper patient preparation and technique. In anticipated difficult airway, the preferred choice of airway management is awake fibreoptic bronchoscopy (FOB), which requires ample amount of expertise and experience. We present a case of difficult airway with extremely restricted mouth opening which was managed by using the barrel of a syringe as an added guide for FOB.

Keywords: Difficult airway, endotracheal intubation, fibreoptic bronchoscope

How to cite this article:
Singh PR, Tiwari T, Tewari V, Singh GP. Fibreoptic intubation in an adult with restricted mouth opening facilitated by improvised bite block from the barrel of syringe. Airway 2019;2:151-3

How to cite this URL:
Singh PR, Tiwari T, Tewari V, Singh GP. Fibreoptic intubation in an adult with restricted mouth opening facilitated by improvised bite block from the barrel of syringe. Airway [serial online] 2019 [cited 2023 Mar 30];2:151-3. Available from: https://www.arwy.org/text.asp?2019/2/3/151/277324

Introduction

Adept airway management is an essential skill for an anaesthesiologist. Managing a difficult airway has always been a major concern to an anaesthesiologist. Airway-related complications are one of the most common causes for anaesthesia-related morbidity and mortality. Difficult intubation can occur because of anatomical abnormalities or situational factors such as airway inflammation.^[1]

Case Report

A 24-year-old lady presented to the Department of Plastic Surgery of King George's Medical University, Lucknow, India, with facial disfigurement following a bite injury. During the preanaesthetic checkup, the patient was declared physically fit (American Society of Anesthesiologists Physical Status I). Due to the injury inflicted on the patient, the airway was difficult as both the external nares were obliterated, and the mouth opening was very much restricted [Figure 1].

Figure 1: Clinical photograph showing limited mouth opening and block of both the nares

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On the day of surgery, the patient was shifted to the operating room and placed in a semi-propped up position, and all standard monitors were attached. Bilateral superior laryngeal nerve block with 2 mL of 2% lignocaine was given at the greater cornu of the hyoid bone. A transtracheal injection of 2% lignocaine was also administered. Just before the fibreoptic bronchoscope (FOB) was inserted, two puffs of 10% lignocaine spray were sprayed onto the posterior pharyngeal wall.

Attempts to insert an oral bite block were unsuccessful as the injury had extended onto the left angle of the mouth resulting in restricted mouth opening. As the standard bite block could not be introduced, we modified the barrel of a 10 mL syringe to improvise a bite block [Figure 2]. After removing the plunger, the nozzle end of the barrel of a 10 mL syringe was cut and smoothened before using it as a bite block. The FOB with the armoured tube was passed through this 'bite block' [Figure 3].

Figure 2: Bite block created from the barrel of a 10 mL syringe (plunger removed) and the nozzle end cut and smoothened

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Figure 3: Fibreoptic bronchoscope with preloaded armoured tube passing through the improvised 'bite block'

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The FOB was checked, and a 6.5 mm ID cuffed endotracheal tube (ETT) was preloaded over it. As both the nares were obliterated, the scope had to be introduced through the mouth. The fibrescope was inserted into the oral cavity through the right angle of the mouth with the improvised 'bite block' positioned between the teeth. After negotiating the upper airway and the vocal cords, the trachea was entered and the carina was visualised. The ETT was then railroaded over the bronchoscope into the trachea. Correct placement of the tube was confirmed by fibreoptic viewing of tube tip inside the trachea, inability to vocalise and presence of a square wave capnographic trace. The patient withstood the procedure well. Anaesthesia was then induced with propofol 2 mg/kg and vecuronium 0.1 mg/kg and maintained with sevoflurane and fentanyl. Vital signs were monitored throughout the procedure and the trachea extubated at the end of surgery after confirming adequate antagonism of residual neuromuscular blockade.

Discussion

A difficult airway is a clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation, tracheal intubation or both.^[2] Many devices and techniques are now available to circumvent the challenges encountered with a difficult airway. ETT guides, different types and sizes of laryngoscope blades, supraglottic airway devices, lighted stylets, rigid videolaryngoscopes and indirect fibreoptic laryngoscopes are a few options included in this extensive list. However, awake fibreoptic intubation still remains the gold standard for anticipated difficult intubation.^[3],[4]

Although blind nasal or oral intubation is a simple technique, it is associated with two major drawbacks such as infrequent success on the first pass and increasing tissue trauma with repeated attempts. Furthermore, the FOB provides a more definitive and less traumatic means to gain endotracheal access under vision. Blind nasal or oral intubation is a dying art which, with the availability of better technology and advanced instrumentation, will soon be relegated to history.

In our case with extremely restricted mouth opening, the use of a supraglottic airway device such as a laryngeal mask airway or an i-gel was thought to be impractical.^[5],[6] Elective tracheostomy under local anaesthesia has been considered the 'definitive' modality of airway management in difficult situations.^[7],[8],[9] Nevertheless, it may be difficult or impossible in certain cases such as huge neck mass and burn contracture of the neck with fixed flexion deformity.

Conclusion

Choosing an appropriate technique for the management of both anticipated and unanticipated difficult airway is the first step. The airway management strategy should next be executed wisely and precisely using appropriate airway devices. Thorough knowledge and skill in all the techniques are mandatory as mismanaged difficult airways can lead to disastrous consequences.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for her image and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors would like to thank the Department of Plastic Surgery, KGMU, Lucknow, Uttar Pradesh, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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