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CASE REPORT Table of Contents  
Ahead of print publication
Awake fibreoptic bronchoscopy-guided nasal intubation in a burn patient: Role in sitting position


 Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission20-May-2022
Date of Acceptance02-Aug-2022
Date of Web Publication07-Oct-2022
 

  Abstract 


Fibreoptic bronchoscopy-guided intubation (FOBI) is ideal in establishing the airway in patients with anticipated difficult airway before the induction of general anaesthesia. At times, patient factors lead to the need for FOBI in unconventional positions. We encountered a patient with postburn contracture with fixed flexion deformity of the neck who was unable to lie supine. Awake FOBI in sitting position turned out to be the ideal position for our patient.

Keywords: Awake intubation, burn airway, fibreoptic intubation, intubation in sitting position, nasal intubation


How to cite this URL:
Loganathan S, Singh A, Naik NB. Awake fibreoptic bronchoscopy-guided nasal intubation in a burn patient: Role in sitting position. Airway [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=358060





  Introduction Top


Postburn contracture (PBC) of the neck and face may result in difficulty in airway management. Contractures lead to distortion of orofacial anatomy and inaccessibility to the front of the neck making airway management more challenging. Contractures involving the anterior neck can be released if possible under local infiltration anaesthesia before airway manipulation. We report a case of burns involving the nape of the neck and back leading to muscle spasm and contracture and posing a challenge during anaesthesia.


  Case Report Top


A 23-year-old male with a history of thermal burns 3 months before was referred to the Burn Unit of the Department of Plastic Surgery for tertiary care management. The burn area involved the face, chest, back, neck (front and back), upper limbs and abdomen (45%). The initial management of burns was done in a district-level government hospital for a month. The patient was then discharged and advised to go to a tertiary care hospital for further management. He presented to our hospital only 2 months after discharge. In between, he was on indigenous treatment for the burns. He was noncompliant to physiotherapy.

On examination, he was found to have partially healed ulcers and scars in the burnt area. As he was unable to lie supine, he slept in the sitting position with the head flexed. This resulted in a fixed flexion deformity of the neck [Figure 1].
Figure 1: The patient in sitting position

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He was admitted on this occasion for debridement of the burn wound and skin grafting. He had no comorbid illness and laboratory investigations were within normal limits. During preanaesthetic checkup on the day before surgery, we tried to extend the neck to a neutral position. Because of the severe pain and contracture of neck muscles, he could not move the neck even by an extent of 5°. As he was being cared for in a high-dependency unit and was under close monitoring, he was receiving morphine 3 mg intravenously (IV) three times a day for pain. PBCs were seen over the face and mouth opening was restricted to two finger breadths. We could not appreciate the other details of airway examination in this position. He was counselled and scheduled for awake fibreoptic bronchoscopy-guided nasal intubation.

After adequate fasting, glycopyrrolate 0.2 mg was given IV 30 min before taking the patient into the operating room (OR). The airway mucosa was anaesthetised with 4 mL of 4% lignocaine nebulisation and nostrils packed with Merocel® soaked in lignocaine:adrenaline mixture (5:1). Airway blocks, transtracheal lignocaine, lignocaine gargle and spray were not possible because of inaccessibility to the front of the neck and oral cavity.

In the OR, we tried to make the patient lie supine by supporting the back with cotton padding and pillows. A bolus of 50 μg fentanyl was given for pain relief. He reported a reduction in pain but was still unable to lie flat and extend the neck. A decision was taken to proceed with awake FOB-guided nasal intubation in the sitting position. He was given 100% oxygen through a face mask, but a complete mask seal was not possible because of the patient's position. The FOB was introduced and advanced while spraying the mucosa with 2% lignocaine. The tube was successfully placed in the trachea and we proceeded with induction of anaesthesia. After the administration of muscle relaxants, we were able to extend the neck and the patient was made to lie down supine. Surgery was done in both supine and prone positions.


  Discussion Top


PBC of the neck and face distorts the airway anatomy and makes the airway access a challenge for the anaesthesiologist during the perioperative period. During the acute phase of burns, adequate pain relief and active physiotherapy help in preventing contracture formation in the skin, soft tissue and underlying muscles.[1]

Our patient had a fixed flexion deformity of the neck and was not able to lie supine. This can be explained by severe pain during movement and PBCs developing over the partially healed ulcers. High-dose opioid induction could relieve pain and spasm. However, if the deformity was due purely to contracture, this would lead to a catastrophe because of airway loss following induction of anaesthesia. Hence, the decision was made to perform FOB-guided intubation in the sitting position. The airway management plan in this patient is detailed in [Figure 2].[2]
Figure 2: Detailed plan of airway management in the patient with postburn contracture and fixed flexion deformity of the neck

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Proper counselling and preparation of the airway makes the patient more comfortable and the procedure more convenient for the anaesthesiologist. Airway blocks are not possible in patients where access to the front of the neck is limited. Antisialagogues, nebulisation with lignocaine and local anaesthetic 'spray-as-you-go' technique were the available options for airway preparation. Awake sitting FOB-guided intubation is commonly used in patients with a neck mass compressing the airway producing stridor and in patients with respiratory distress while lying supine.[3],[4] Conventionally, awake FOB-guided intubations are performed from the head end in the supine patient. In our case, the forward bending posture and fixed flexion deformity of the neck of the patient helped in clearing the secretions away from the glottis by gravity. In addition, gravity-aided guidance of the FOB towards the glottis was relatively easy. We faced initial difficulty in interpreting the inverted orientation to FOB images. Jaw thrust was not possible in this position and was not required in this case.

Successful intubation was reported in the sitting position with awake FOB technique in failed oral/nasal awake FOB-guided intubations in the supine position.[5] While FOB-guided intubation is the gold standard in the management of difficult airway, it has a steep learning curve.[6] Awake sitting FOB-guided intubation is useful in patients who are unable to lie supine and offers an advantage of gravity on respiratory function and decreased risk for aspiration.[7]


  Conclusion Top


Patient factors could lead to the need for performing intubations in unconventional positions. The sitting position turned out to be the best for intubating our patient with fixed flexion neck deformity following burns.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goverman J, Mathews K, Goldstein R, Holavanahalli R, Kowalske K, Esselman P, et al. Adult contractures in burn injury: A burn model system national database study. J Burn Care Res 2017;38:e328-36.  Back to cited text no. 1
    
2.
Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway. Can J Anaesth 2013;60:1119-38.  Back to cited text no. 2
    
3.
Kumar KR, Selvam SR, Priya B. Awake fibreoptic bronchoscopy guided intubation – Significance of sitting position. Indian J Anaesth 2018;62:910-1.  Back to cited text no. 3
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4.
Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, et al. A rapidly enlarging neck mass: The role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627-9.  Back to cited text no. 4
    
5.
Etemadi SH, Bahrami A, Farahmand AM, Zamani MM. Sitting nasal intubation with fiberoptic in an elective mandible surgery under general anesthesia. Anesth Pain Med 2015;5:e29299.  Back to cited text no. 5
    
6.
Collins SR, Blank RS. Fiberoptic intubation: An overview and update. Respir Care 2014;59:865-78.  Back to cited text no. 6
    
7.
Wong J, Lee JS, Wong TG, Iqbal R, Wong P. Fibreoptic intubation in airway management: A review article. Singapore Med J 2019;60:110-8.  Back to cited text no. 7
    

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Correspondence Address:
Ajay Singh,
Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None



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    -  Loganathan S
    -  Singh A
    -  Naik NB


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