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| CASE REPORT |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 26-28 |
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Direct laryngoscopy-assisted flexible bronchoscopic intubation in a difficult airway
Harshal D Wagh
Department of Anaesthesia, Kokilaben Ambani Hospital, Mumbai, Maharashtra, India
| Date of Submission | 07-Dec-2022 |
| Date of Acceptance | 28-Dec-2022 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Dr. Harshal D Wagh
Department of Anaesthesia, Kokilaben Ambani Hospital, Mumbai - 400 053, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/arwy.arwy_47_22
Neck masses may distort the airway and make even fibreoptic intubation difficult. A large mass may prevent the negotiation of a flexible bronchoscope beyond the obstruction. A combined direct laryngoscopy-assisted flexible bronchoscopy must be considered an option that can help intubation in select difficult airway situations and may prove lifesaving as it did in this case.
Keywords: Bronchoscopy, intubation, laryngoscopy
How to cite this article:
Wagh HD. Direct laryngoscopy-assisted flexible bronchoscopic intubation in a difficult airway. Airway 2023;6:26-8 |
| Introduction | |  |
Neck masses may distort the airway and make even fibreoptic intubation, the gold standard in difficult intubations, difficult. A large mass may prevent the negotiation of a flexible bronchoscope beyond the obstruction. Leveraging the obstruction with either a direct laryngoscope or video laryngoscope,[1],[2] to allow a flexible bronchoscope to be negotiated beyond the obstruction can be considered. This case report highlights how a direct laryngoscopy-assisted flexible bronchoscopic intubation in a difficult airway proved lifesaving.
| Case Report | | |
A 62-year-old male patient underwent a major oral cancer resection with a free microvascular reconstruction flap. In addition to other comorbidities, the patient had a high body mass index, so an elective tracheostomy was done, which was also a difficult procedure. Postoperatively the following day in the intensive care unit, the tracheostomy tube inadvertently got dislodged. Multiple attempts at reintroducing the tracheostomy tube were unsuccessful. Mask ventilation proved extremely difficult, with a large free flap occupying most of the oropharyngeal cavity. The flap also prevented any direct laryngoscopic view of the vocal cords. Multiple attempts were made in vain at re-inserting the tracheostomy tube as well as direct laryngoscopy. This led to bleeding at the tracheostomy site and in the oropharynx further compromising the oxygenation. A flexible bronchoscope introduced nasally could not negotiate the large flap that occupied the whole of the oropharynx. The bleeding made visualisation and identification of any landmarks in the oropharyngeal cavity extremely difficult. Intermittent attempts at bag-mask ventilation with 100% oxygen kept the oxygenation level at 75%–80% with an impending hypoxic arrest situation. Finally, a combined effort of one anaesthesiologist performing a direct laryngoscopy with a McCoy size 4 laryngoscopy blade and another anaesthesiologist performing a nasal intubation with the help of a flexible bronchoscope proved successful. The direct laryngoscopy helped to displace the large flap. The displacement of the flap allowed effective suctioning of the collected blood and secretions. This allowed the flexible bronchoscope to negotiate the obstruction. This resulted in a partial but relatively clear view of the larynx that helped successful endotracheal insertion of the endotracheal size 7 over the bronchoscope.
| Discussion | | |
Asai and Shingu stated that the paucity of the normal anatomical space between the posterior pharyngeal wall and the larynx was a typical reason to lose out endotracheal intubation when a flexible fibrescope was used.[3]
Nasal intubation may be challenging if there is nasopharyngeal bleeding, altered airway anatomy or difficulty in advancing the endotracheal tube through the glottis. Trauma, blood and secretions may inhibit navigation with just a fibreoptic bronchoscope despite preventative measures.[4],[5] Direct laryngoscopy can provide much-needed leverage to displace the obstructing mass, allowing effective suction of blood and secretions and negotiation of the flexible bronchoscope beyond the obstruction to view the vocal cords.
Kumar et al. reported a similar combined method to intubate a patient with a large supraglottic vallecular haemangioma.[6]
A video-assisted fibreoptic intubation technique has been suggested.[7] A video laryngoscope is used to obtain the best possible glottic view and a fibrescope preloaded with a tracheal tube is introduced to intubate the trachea. This allows the practitioner the option of using both video screens for optimal vision.
Video laryngoscopy is proving to give a better laryngoscopic view, with lesser trauma and complications than conventional laryngoscopy.[8],[9]
| Conclusion | | |
A combined direct laryngoscopy or video laryngoscopy-assisted flexible bronchoscopy must be considered an option that can help intubation in select difficult airway situations and may prove lifesaving.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for his/her images and other clinical information to be reported in the journal. The patient understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Acknowledgement
I would like to thank Dr Mandar Deshpande, Consultant, Head and Neck Onco Surgeon, KDAH for his guidance and support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Nedrud SM, Baasch DG, Cabral JD, McEwen DS, Dasika J. Combined video laryngoscope and fiberoptic nasal intubation. Cureus 2021;13:e19482. |
| 3. | Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: Incidence, causes and solutions. Br J Anaesth 2004;92:870-81. |
| 4. | Adamson DN, Theisen FC, Barrett KC. Effect of mechanical dilation on nasotracheal intubation. J Oral Maxillofac Surg 1988;46:372-5.5. |
| 5. | Lu PP, Liu HP, Shyr MH, Ho AC, Wang YL, Tan PP, et al. Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation. Acta Anaesthesiol Sin 1998;36:193-7. |
| 6. | Kumar R, Sahay N, Bharti B, Kumar A. Laryngoscopy-assisted fiberoptic intubation in an adult with a large vallecular haemangioma. Indian J Anaesth 2020;64:907-9. [Full text] |
| 7. | Sanfilippo F, Chiaramonte G, Sgalambro F. Video laryngoscopes and best rescue strategy for unexpected difficult airways: Do not forget a combined approach with flexible bronchoscopy! Anesthesiology 2017;126:1203. |
| 8. | Kakkolil MP, Nair VA, Devi BR, Mohanan Nair JK, Rachel CK. Direct laryngoscopy versus video laryngoscopy for expected difficult tracheal intubation a prospective study. Indian J Clin Anaesth 2021;8:277-82. |
| 9. | Panwar N, Vanjare H, Kumari M, Bhatia VS, Arora KK. Comparison of video laryngoscopy and direct laryngoscopy during endotracheal intubation – A prospective comparative randomized study. Indian J Clin Anaesth 2020;7:438-43. |
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