(Acta Anaesth. Belg., 2015, 66, 87-90) A novel … study, a ‘can’t intubate, can’t...
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Transcript of (Acta Anaesth. Belg., 2015, 66, 87-90) A novel … study, a ‘can’t intubate, can’t...
© Acta Anæsthesiologica Belgica, 2015, 66, n° 3
Abstract : Introduction : Expertise in airway management is a fundamental aspect of anesthesia practice. Fortunately ‘can’t intubate, can’t ventilate’ scenarios are extremely rare. In particular, patients with tumors on the right side of the oropharynx and larynx can be very problematic to intubate.Methods : We present an alternative intubation technique, whereby a CMAC Dblade videolaryngoscope is loaded with a Frova catheter in the narrow, curving channel within the blade’s inferoposterior aspect on the left side of the blade. This technique can be a successful alternativeinpatientswithdifficultairways.Results : The proposed technique was successfully demonstrated in a case whereby a 47year old male with premetrics of a difficult airway, presentedwith a largemass in the right supraglottis and hypopharynx with through-and-through thyroid cartilage infiltration, obstructing completely the view of the glottis with direct laryngoscopy. The referral hospital considered the patient unintubatable and sent the patient to our academic center for treatment. Endotracheal intubation with the newtechniquewassuccessfulatthefirstattempt.Conclusions : The CMAC DBlade videolaryngoscopebougie technique provides an alternative method to intubatepatientswithdifficultairways,eveninexceptionalsituations such as in patients with a large rightsided oropharynxlarynx tumor.
Key words : Larynx tumor ; failed intubation ; CICO ; videolaryngoscopy ; frova catheter.
IntroductIon
Endotracheal intubation can be challenging in patients with difficult airways. According to theNAP4study, a ‘can’t intubate, can’t ventilate’ scenario occurs in fewer than 1 in 5,000 routine general anesthesia procedures, but accounts for up to 25% of all anesthesiarelated deaths (14).
Videolaryngoscopy offers advantages over classic laryngoscopy, especially in patients with difficultairways(5-7).Wesuggestanalternativeintubation method to those currently available by utilising the CMAC®Dblade (8) videolaryngoscope
(Karl Storz, Tuttlingen, Germany) and a bougie/ introducer with a ‘railroad’ technique.
case report
A 47yrold indigenous male (height : 160 cm ; weight : 54 kg ; BMI : 21 kg/m2 ; ASA 4, Mallampati grade IV, mouth opening 2 cm, thyromental distance 5.2 cm) presented with a 2 week history of dysphagia and hemoptysis. He was a longterm chronic alcohol abuser and smoker, and reported recent 510 kg of weight loss and hypertension. Chest Xray showed the appearance of a rightsided laryngeal tumor with an abnormal lymph node, deemed likelytobemalignant.CTscanconfirmedalaryngeal primary tumor eroding into the thyroid cartilage staged at T4aN2M0, obliterating completely the right side of the glottis entrance. PET scan demonstrated a mass in the right supraglottis and hypopharynx with throughandthrough thyroid cartilage infiltrationandbilateralnodalmetastases.Incidentally, the right palate also appeared ‘hot’ on PET scan. Flexible nasal endoscopy showed a large supraglottic lesion on the right false cord extending
(Acta Anaesth. Belg., 2015, 66, 87-90)
André A. J. Van Zundert, Professor of Anaesthesiology, M.D., Ph.D., F.R.C.A., E.D.R.A., F.A.N.Z.C.A ; Stephen P. Gatt, Associate Professor of Anaesthesiology, M.D., F.A.N.Z.C.A., F.R.C.A., F.C.I.C.M.
(*) Department of Anaesthesiology and Perioperative Medicine, The University of Queensland School of Medicine & Royal Brisbane & Women’s Hospital, Brisbane, Qld, Australia.
(**) Department of Anaesthesia, Wales Anaesthesia, Prince of Wales Hospital and the University of New South Wales, Randwick, NSW, Australia.
Corresponding address : Prof. André Van Zundert, Professor & Chair Discipline of Anesthesiology, The University of Queensland, Faculty of Medicine & Biomedical Sciences, Royal Brisbane & Women’s Hospital, Ned Hanlon Building – level 4, Department of Anaesthesia & Perioperative Medicine, Butterfield St, Herston-Brisbane, Queensland 4029,Australia. Tel. : +61 7 3646 5673. Fax : + 61 7 3646 1308. Email : [email protected] and
A novel method of intubation and orogastric tube insertion using a CMACDblade videolaryngoscopebougie technique
a. a. J. Van Zundert (*) and s. p. Gatt (**)
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88 a. a. J. Van Zundert and s. p. Gatt
blade’s inferoposterior aspect on the left side of the blade (Fig. 1C1D) which can accommodate a 70cmlong 14Fr Single Use Frova Airway Intubating Introducer/oral endotracheal tube changer (CookTM Bjaeverskov, Denmark) or, alternatively, a 70cm 15Fr Teflon Single Use Exchange GuideBougie with Coudé Tip (Smiths Medical Int., Hythe, Kent, UK), provided both the channel and introducer are well lubricated before use. This technique has proven to be most satisfactory and is an additional, easy-to-implement strategy when difficult airwayintubation is anticipated and when rightsided oral tumors obliterate the view or access to the glottis entrance.
In order to insure successful endotracheal tube placement into the airway using this technique, the following steps are necessary : 1) lubrication of the Frova Introducer or bougie (catheter) and internal surface of the DBlade channel ; 2) loading of the lubricated intubating catheter into position onto the Dblade (Fig. 1C1D) with the catheter tip protruding no further than the Dblade distal end ; 3) holding the videolaryngoscope in either the left or right hand, carefull progression of the Dblade with bougie/intubating catheter/exchange catheter assembly into the mouth under direct vision ; 4) obtaining a view on the CMAC screen in the standard recommended fashion ; 5) positioning of the tip of the Dblade into the vallecula under guidance using the image on the CMAC monitor screen (Fig. 1E) ; 6) pointing the tip of the Frova intubating introducer/bougie to face the middle of the glottic entrance (which will usually now be visible in the center of the monitor screen) ; 7) using the free hand to advance the tip of the bougie/intubating catheter and inserting it about 7 cm over the vocal cords into the trachea (Fig. 1E) ; 8) removing the Dblade and unclip the catheter from the channel whilst holding firmlyontothebougie/intubatingcatheterjustoutside the lips to retain the catheter’s intratracheal position;9)loadingbyatrainedassistantnowtheendotracheal tube onto the proximal end of the bougie/intubating catheter/exchange catheter ; and 10) using the latter to railroad the endotracheal tube into the trachea (Fig. 1F). While this last step can be undertaken ‘blind’ as in the standard blind railroad technique, it can be conducted under continuous visual guidance if the Dblade (Fig. 1G) is reinserted into the mouth.
According to the anesthesiologist preference, the videolaryngoscope can be held in the left or the right hand, while the free hand can be used to advance the bougie (catheter). This avoids the need to “cross” hands. Experience has shown us that, in
to the aryepiglottic fold. The right anterior glottis could not be viewed because of the tumor. At the time of presentation, the patient had acute airway obstruction at the level of the larynx, presumably from his carcinoma.
The patient had been transferred to our hospital (RBWH) for surgery because he was deemed ‘unintubatable’ and because of the magnitude of the surgery required. Because the patient could not be intubated, a tracheostomy had been performed under local anesthesia before transfer. Surgeons planned : a 1) pharyngolaryngectomy and esophagectomy ; 2) esophageal replacement using a stomachpull-up;3)reanostomosis(jejunalflaprepair);4) right 15 area neck dissection ; and 5) left 24 zone neck dissection. The tumor was known to be large, fragile to the point of crumbling when touched and bleeding when interfered with.
Because surgery included removal and excision of the tracheostomy area an oral/nasal endotracheal tube (ETT) was needed and, in the operating theatre, both the ENT and maxillofacial surgeons chose the oral route even though MRI studies suggested that intubation would not be possible. We induced anesthesia using the intravenous route because we had the advantage of the tracheostomy. In this case, a blind retrograde technique through the existing tracheostomy would have been inappropriate both in advancing the Seldinger wire or tube changer and the subsequent railroad technique because of the size and friability of the tumor.
We opted for the CMACDblade with Frova asfirstlinetechniquebecauseweregardedourtechnique as the most likely to be successful. Though previously regarded as impossible, we eased the blade gingerly down the left side carefully avoiding the large tumor on the right side. The left cord was visible but the right cord was obliterated by the large invading laryngeal tumor (Fig. 1A). An enlarged epiglottis made the intubation more complex. Once the CMACDblade/Frova catheter technique identifiedthetracheostomy,arailroadintubationonthefirstattemptwaspossible, straightforwardand‘easy’. As anticipated, there was minor bleeding from the tumor (Fig. 1B). This ceased within a few seconds. Operation and recovery were uneventful. Patient gave written consent for publication.
dIscussIon
The CMAC®Dblade, designed by Professor dr. Volker Dörges (University of Kiel Germany) features a narrow, curving channel within the
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c-mac-d-blade videolaryngoscope-bougie technique 89
Fig. 1. — Picture taken with videolaryngoscopy of a patient with a large invading laryngeal tumor on the right, oblit-erating the anterior view of the glottis, before (Fig. 1A) and after (Fig. 1B) endotracheal intubation, with a nasogastric tube in position ; and the sequence of insertion using the C-MAC D-blade videolaryngoscope, mounted with an intu-bating catheter (Fig. 1C to 1G). Note the clear difference between the tracheal and esophageal orifices (Fig. 1H).
A
E
G
C
B
F
H
D
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adjunct manipulation techniques during a successful endotracheal tube insertion.
conclusIon
Our new intubation technique provides to the operator a simple sequence, with small investment in time, to achieve a rapid, satisfactory outcome even in those where attempts at intubation have proved unsuccessful. Furthermore, it provides another application of the CMAC®DBlade. Unlike the situation with other videolaryngoscopes, both direct and indirect laryngoscopy can be performed and both a ‘channelled’ (using the unique, previously unpublished, technique described in this paper) and ‘unchannelled’ method are possible.
References
1. Woodall N. M., Cook T. M., National census of airway management techniques used for anaesthesia in the UK : first phase of the 4th National Audit Project at the Royal College of Anaesthetists, br. J. anaesth., 106, 26671, 2011.
2. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, Major complications of airway management in the United Kingdom. Report and Findings,ISBN978-1-9000936-03-3.Royal College of Anaesthetists, London, 2011.
3. Cook T. M., MacDougallDavis S. R., Complications and failure of airway management, br. J. anaesth., 109 (S1), i68i85b, 2012.
4. Cook T. M., Woodall N., Frerk C., Major complications of airway management in the United Kingdom. 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society Part 1 Anaesthesia, br. J. anaesth., 106, 61731, 2011.
5. Van Zundert A. A. J., Maassen R. L. J. G., Hermans B., Lee R. A., Videolaryngoscopy – making intubation more successful, acta anaesthesIol. belG., 59, 17717, 2008.
6. Maassen R., Lee R., van Zundert A., Cooper R., The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient. J. anesth., 23,445-8,2009.
7. van Zundert A., Pieters B., Hoogbergen M., Videolaryn-goscopy offers advantages over classic laryngoscopy in a patient with seriously limited lip opening, J. anesth., 26, 468-9,2012.
8. Cavus E., Neumann T., Doerges V., Scharf E., Wagner K., Bein B., Serocki G., First clinical evaluation of the C-MAC D-blade videolaryngoscope during routine and difficult intubation, anesth. analG., 112, 3825, 2011.
9. Greenland K. B., Bradley P., D-blade C-MAC videolaryn-goscopy™ with the Frova Intubating Introducer™, anaesth. IntensIVe care, 43,268-9,2015.
either case, crossing hands is not really a problem because the distal end of the laryngoscope handle and the catheter are in very close proximity.
If an orogastric tube also needs to be inserted, an identical technique can be used. This time the orogastric tube is loaded into the Dblade channel while the blade tip is adjusted to sit slightly more posteriorly to face the esophagus. With the tip of the blade in position, one can clearly distinguish the esophageal orifice from the glottic entrance(Fig. 1H).
The narrow, curving channel can also be used to administer oxygen during the process of intubation (if a Frova or Cook exchange catheter is used) or to suction the oropharynx and clear any blood or saliva (if a long Y suction catheter is used). The anesthesiologist should test, before use on patients, whether the oxygen delivery catheter or suction catheter (eg. Y-suction) fits snugly within the channel.
If the tip of the intubating catheter points too high onto the anterior commissure and, therefore, is anterosuperior to the vocal cords, this can prevent from being able to insert the endotracheal tube into the trachea. This can be solved by withdrawing the Dblade further by 12 cm and by gently rotating the bevel of the endotracheal tube counterclockwise during the railroad procedure.
If dislocation of the airway intubating catheter was to occur during a blind railroad procedure, the procedure would need to be repeated, this time ensuring that the catheter sits within the trachea whilst, at the same time, monitoring and correcting peripheral oxygenation. This was not necessary in any of our subjects.
This new technique is easy to learn and to teach to others. We have used this method in over fiftypatientswithpremetricssuggestingadifficultairway. All intubations using this technique were successfulonthefirstattempt.Myco-workerKeithGreenland also mentioned our new technique in a casereportedintheAustralianliterature(9).
Further studies may be helpful to : 1) further validate our novel suggested method ; 2) compare our technique in difficult airways with a controlgroup in which the bougie is not used ; 3) demonstrate the optimal qualities and physical properties of the introducer ; and 4) validate the sequence and
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