|Year : 2023 | Volume
| Issue : 1 | Page : 29-31
Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis
Senthilkumar Praveenkumar1, Hemlata Kapoor1, Deepika Malapaka2
1 Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Mumbai, Maharashtra, India
2 Department of Anaesthesia, ESIC Hospital, Mumbai, Maharashtra, India
|Date of Submission||19-Aug-2022|
|Date of Acceptance||24-Dec-2022|
|Date of Web Publication||20-Apr-2023|
Dr. Senthilkumar Praveenkumar
Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Bungalows, Mumbai - 400 053, Maharashtra
Source of Support: None, Conflict of Interest: None
Patients with ankylosing spondylitis present with airway difficulties. There are various techniques to secure a definitive airway for general anaesthesia in these patients. We report the case of an ankylosing spondylitis patient with fixed neck deformity for laparoscopic bilateral inguinal hernia repair surgery managed with an Ambu® AuraGain™ laryngeal mask (LM) insertion and followed by a fibreoptic bronchoscopic-aided endotracheal tube insertion for definitive airway through the LM airway according to the All India Difficult Airway Association guidelines.
Keywords: Ankylosing spondylitis, bronchoscopy, difficult airway, endotracheal tube, general anaesthesia, laryngeal mask
|How to cite this article:|
Praveenkumar S, Kapoor H, Malapaka D. Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis. Airway 2023;6:29-31
|How to cite this URL:|
Praveenkumar S, Kapoor H, Malapaka D. Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis. Airway [serial online] 2023 [cited 2023 Jun 7];6:29-31. Available from: https://www.arwy.org/text.asp?2023/6/1/29/374365
| Introduction|| |
Ankylosing spondylitis is a progressive autoimmune disease of the axial skeleton more common in males. It causes annular fibrous ossification of joint cartilage and disc spaces of the spine. Ankylosis of the axial skeleton causes fusion and rigidity of the spine. Involvement of the cervical spine reduces neck extension causing a 'chin-on-chest' deformity which poses a challenge in airway management. Conventional airway-securing techniques are often difficult and awake fibreoptic intubation is often necessary for these patients.
We present a patient with ankylosing spondylitis with fixed neck deformity posted for laparoscopic bilateral inguinal hernia repair.
| Case Report|| |
A 50-year-old male with ankylosing spondylitis for 10 years was admitted for laparoscopic bilateral inguinal hernia repair. On examination, he had a fixed neck flexion deformity and required two pillows for resting his head in supine position as shown in [Figure 1]. His Mallampati classification was grade IV and the sternomental distance was reduced as shown in [Figure 2]. There was no neck extension. Our patient had adequate mouth opening. These patients are prone to atlantoaxial dislocation, hence the head was adequately supported. The rest of the general and systemic examinations were normal. Routine blood investigations were normal. Two-dimensional echocardiography showed all normal parameters. General anaesthesia was planned for the patient and the placement of endotracheal tube (ETT) with fibreoptic bronchoscope was planned and explained to the patient in detail. Before wheeling the patient into the operation theatre, lignocaine 4% nebulisation was given in the prehold bay. In the operation theatre, two pillows were given to support his neck and Trendelenburg position was given to aid mask ventilation.
|Figure 1: View of the patient at the head end showing the distance between the head and the floor – fixed neck deformity|
Click here to view
Electrocardiogram, pulse oximetry and noninvasive blood pressure cuff were attached. The nasal tract was decongested with xylometazoline nasal drops and lignocaine jelly topical anaesthesia was given. However, the patient was uncooperative during awake fibreoptic intubation and refused further cooperation. The patient's mouth opening was not restricted and was found to be adequate; therefore, we planned to insert supraglottic device in the oral cavity. Inj. glycopyrrolate 0.2 mg iv was given. General anaesthesia was induced with propofol 2 mg/kg and atracurium 0.5 mg/kg was given. A laryngeal mask (LM) (Ambu® AuraGain™) was placed. The LM achieved proper seal and adequate expired tidal volume was attained. After this with the help of Ambu aScope™ 4 Broncho Regular flexible endoscope, bronchoscopy was done through the LM and the vocal cords were visualised. A preloaded portex-cuffed ETT 7.0 was railroaded over the bronchoscope. The bronchoscope was removed and the correct placement of ETT was confirmed with appearance of proper capnograph. The LM was not removed as it was a shorter duration surgery and it could be helpful during extubation. Anaesthesia was maintained with sevoflurane in air–oxygen mixture. At the end of the surgery, after adequate reversal, the ETT was removed, but the LM was left in place. Once the patient was wide awake, the LM was removed. The patient was shifted to the postanaesthesia care unit and had an uneventful recovery.
| Discussion|| |
Ankylosing spondylitis patients present with various difficulties for the anaesthesiologist to manage them with respect to the airway and systemic involvement for general anaesthesia. The involvement of the cervical spine and the temporomandibular joint causing a fixed neck deformity of various degrees. The cervical spine is prone to fractures during manipulations and this should be taken into consideration to avoid neurological injury and complications.
Undue force cannot be applied during laryngoscopy and intubation. Awake fibreoptic bronchoscopic intubation is the standard technique in patients with anticipated difficult intubation. There are various strategies which can be carried out to secure the difficult airway for surgery depending on the availability of airway devices and the expertise. Blind nasal intubation, tracheostomy, Bullard laryngoscope, retrograde intubation, GlideScope, Pentax Airway Scope, LMA FastTrack, TruView EVO2 optical laryngoscope and the Aintree Intubation Catheter-guided fibreoptic intubation through a laryngeal mask airway have been used to secure the airway in patients with ankylosing spondylitis successfully.
Our initial plan of proceeding with an awake fibreoptic intubation had to be abandoned as the patient became uncooperative. Since mouth opening for LM placement was found to be adequate, we chose to place an LM. In case general anaesthesia could not be given, the plan was to change the surgical plan to open hernia repair under nerve block. Ambu® AuraGain™ LM is routinely used in our institute. We planned to insert number 4 Ambu® AuraGain™ LM after confirming adequate ventilation under sedation with fentanyl, propofol and sevoflurane. The 2016 All India Difficult Airway Association guidelines do not recommend the use of ETT to be passed through the LM blindly. We used a preloaded ETT of size 7 over an Ambu aScope™ 4 Broncho Regular flexible endoscope and railroaded it through the LM after a clear unobstructed view of the glottis seen. The assembly of the airway gadgets used is shown in [Figure 3]. The largest ETT that can be passed through the number 4 Ambu® AuraGain™ LM is 7.5 mm. On examination, the laryngeal mask placement was feasible and the ETT was guided through it for the laparoscopic surgery. Amongst many supraglottic airway devices, Ambu® AuraGain™ LM is a newer supraglottic airway designed to have an anatomical curve for smooth insertion and an adequate lumen for the passage of ETT.
| Conclusion|| |
Our technique of securing an ETT through an Ambu LM is a suggested technique for patients with fixed neck deformity when the patient does not give consent for an awake fibreoptic intubation. The advantages of this relatively newer supraglottic airway device are promising in difficult airway situations. However, case-based strategies need to be designed to manage such patients of ankylosing spondylitis with myriad airway difficulties based on the availability of airway gadgets.
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 his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: An overview. Ann Rheum Dis 2002;61 Suppl 3:i8-18.
Saringcarinkul A. Anesthetic considerations in severe ankylosing spondylitis. Chiang Mai Med J 2009;48:57-63.
Vikas K. Airway management in a patient with severe Ankylosing Spondylitis. Indian J Basic Appl Med Res 2014;3:251-55.
Woodward LJ, Kam PC. Ankylosing spondylitis: Recent developments and anaesthetic implications. Anaesthesia 2009;64:540-8.
Ul Haq MI, Shamim F, Lal S, Shafiq F. Airway management in a patient with severe ankylosing spondylitis causing bamboo spine: Use of Aintree intubation catheter. J Coll Physicians Surg Pak 2015;25:900-2.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al.
All India difficult airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.
] [Full text]
[Figure 1], [Figure 2], [Figure 3]