Global Journal of Otolaryngology ISSN 2474-7556

Research Article Glob J Otolaryngol Volume 14 Issue 3 - March 2018 Copyright © All rights are reserved by Cecil B Rhodes DOI: 10.19080/GJO.2018.14.555888 Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper Airway Cancer

Francisco OM Vieira1, Cecil B Rhodes2, Aaron Smith2 and Shannan Case CRNA3 1Assistant Professor of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center at Memphis, USA 2Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, USA 3Certified Registered Nurse Anesthetist, University of Tennessee Health Science Center, USA Submission: March 20, 2018; Published: April 06, 2018 *Corresponding author: Cecil B Rhodes, Department of Otolaryngology - Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA, Email:

Abstract Objectives: neck cancer patients presenting with upper airway obstruction who would otherwise undergo initial awake tracheostomy. Methods: We present a combined method of videolaryngoscope assisted fiber optic bronchoscopic intubation “VLS/FOBI” for head and

16 patients presenting with stage III and IV laryngeal, hypopharyngeal and thyroid tumors who were anticipated to be difficult intubations are studied. A combined use of broad view from videolaryngoscope (VLS) assisted by fiber optic bronchoscopic intubation (FOBI) is described.Results: Exposing In this cohortavailable 16 supraglotticout of 38 patients landmarks with head allows and for neck proper cancers positioning met the ofinclusion fiberoptic criteria, flexible 5 (31%) bronchoscope patients althoughto be advanced considered through for the vocal cords and confirmed visually.

the techniqueConclusion: were Advanced not attempted. head and The neck remaining cancer 9patients (69%) patientscan require underwent expedited the awake VLS/FOBI surgical procedure procedures and resulteddue to the in successfulinability to intubations secure the at first pass without any complication. for awake tracheostomy. The equipment is readily available and requires no more time than the standard intubation. airway, which leads to increased risks for complications. However, VLS/FOBI when feasible is easily performed, efficient, and decreases the need Keywords: Airway Intubation Videolaryngoscopy; Videolaryngoscope; Fiberoptic Intubation; Fiber optic Bronchoscopic Intubation; Awake Tracheostomy; Difficult

Introduction Complex analyses have developed predictors that can contribute Recent publications have shown evidence that use of high resolution digital video laryngoscope (VLS), when compared intubation. However, they are far from practical and have a to conventional direct laryngoscope (DL), is superior when to a challenging airway resulting in a difficult or failed airway limited role for routine clinical use.

[1,2] In a large-scale multivariate model Mosier J et al. [3] This limited use is due to the subjective and/or objective managing difficult airways in elective and emergency settings variation in personal skills and different interpretations of a airway management in the emergency department. VLS patient’s airway for the same predictive model [5,6]. Even though compared VLS alone to DL with a MacIntosh blade for difficult appeared to be superior to DL for these cases, improving a thorough preoperative assessment, complications cannot be avoided in many cases and all necessary resources are vital in tracheal intubation. In terms of success rates for rescue attempts, visualization of true vocal cords and increasing efficacy of VLS and DL were equivalent [3]. VLS has been successfully used bronchoscope alone has restrictions and may be limited in managing unanticipated difficult airways [7]. The fiberoptic in assisting rigid bronchoscopic endotracheal in obstructing its use. It offers a narrow frontal view of airway structures. endotracheal neoplastic process for direct stent placement [4]. Also, the primary operator has full control over the procedure

Glob J Otolaryngol 14(3): GJO.MS.ID.555888 (2018) 0070 Global Journal of Otolaryngology and the assistant is restricted to providing only limited help. operator. The VLS is introduced by the assistant operator for a broad inspection of the area, followed by introduction

Furthermore, skill and time management place restrictions desaturation in patients with other associated hemodynamic on the use of the fiberoptic intubation due to rapid oxygen of the fiberoptic bronchoscope (Olympus 5.1mm fiberoptic and respiratory related comorbidities [8]. bronchoscope LF-DP, Tokyo, Japan) with an endotracheal tube stylet for the endotracheal tube and the eyepiece should be placed over the scope. The flexible bronchoscope is used as a preferentially connected to a monitor, providing an accessory intubation include patients with total laryngeal obstruction such Contraindications to attempting fiberoptic bronchoscope view to the anatomy to all assistants involved in the intubation as malignant lesions, airway bleeding, or laryngeal injury and is process [9]. While the assistant gently introduces an adequate relatively contraindicated in patients with moderate subglottic blade size to manipulate and position the VLS to appropriately stenosis or facial trauma with active oropharyngeal bleeding. identify key visible landmarks (epiglottis, arytenoids, false vocal cords and true vocal cords), the operator then introduces the typically results in cricothyroidotomy or awake tracheostomy. Failure of an endotracheal intubation on a difficult airway These options are known to have substantially increased risk toward the area in which the vocal cords are located. of morbidity and mortality, with complications occurring in fiberscope mounted with the endotracheal tube and advances it When the tip of the scope has passed through the vocal about 7% to 8% for this group of patients [9-15]. A combined the endotracheal tube is cautiously advanced into the glottis. intubation technique using fiberoptic bronchoscope intubation cords and placement into the trachea is visually confirmed, was previously described in the literature in 2004 by Doyle [8]. The wide view of 50 degrees from the VLS based on the assisted via video laryngoscope (VLS/FOBI) for difficult airways The combination of these two tools increases the visualization of available supraglottic landmarks allows for monitoring and airway anatomy and can potentially alleviate some of the risk in easy correction of the narrower view from the bronchoscope, especially when any misdirection due to advancing towards the piriform sinus and esophagus. After the endotracheal tube difficult airway intubation. Procedure advancement through the vocal cords, correct placement is anesthesia is induced by a hypnotic and a neuromuscular blocking are carefully removed. The supraglottic view provided by the Following standard monitoring and pre-oxygenation general confirmed by direct visualization and the flexible scope and VLS agent followed by mask ventilation. The technique is performed VLS both before and during insertion of the endotracheal tube is by two operators; one principal operator and one assistant

shown in (Figures 1 & 2).

Figure 1: Video laryngoscope image of fixed right true vocal cord and arytenoid of a supraglottic T3N0M0 squamous cell carcinoma.

How to cite this article: Francisco O V, Cecil B R, Aaron S, Shannan C C. Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper 0071 Airway Cancer. Glob J Oto 2018; 14(3): 555888. DOI: 10.19080/GJO.2018.14.555888 Global Journal of Otolaryngology

Figure 2: Video laryngoscope view of endotracheal tube surrounding fiberoptic bronchoscope and passing through vocal cords.

Methods Results This study was approved by the Institutional Review Board and included 16 out of 38 laryngeal, hypo pharyngeal and thyroid 9 stage IV (56%) patients as seen in Table 1. Out of 16 patients From 16 patients evaluated, there were 7 stage III (44%) and cancer patients spanning a period from 2012 to 2016 who initially attempted with this method due to the anesthesiologist considered for VLS/FOBI, eight (50%) patients were not stage III and IV laryngeal cancer with extension to hypopharynx preference, 5 (31%) were requested securing of the airway by planned to undergo attempted intubation via VLS/FOBI for or hypo pharyngeal cancer extending to the larynx or thyroid awake surgical tracheotomy. Of these, three (19%) were stable cancer with compression/invasion of airway who were airways but the anesthesiologist was unfamiliar with the method. Two patients were unstable and had developed stridor in the anesthesiology for the procedure. These patients also must have morning prior to the procedure due fast progression of the tumor anticipated to be a difficult intubation and had agreement by had a CT scan and were undergoing recent laryngoscopy exam since last laryngoscopy. Three (19%) were tried intubation by and biopsy followed by tracheotomy. We excluded twenty two VLS alone by anesthesiologist, after a failed intubation trial all (58%) patients with stage I and II cancers. We also excluded advanced laryngeal, hypo pharyngeal or thyroid cancers with three were successfully rescued by VLS/FOBI. Eleven patients extensive obstruction of the larynx (Comark-Lahane Grade 4), (69%) intubated by VLS/FOBI procedures resulted in successful to adjacent tissues, bleeding, oxygen desaturation, or loss of intubations at first pass without any complication such as trauma lesions and patients with stridor. supraglottis view that could delay the intubation process. None unidentifiable upper Aerodigestive anatomy, ulcerated or friable of the intubations via this method took longer than 2 minutes. Table 1.

C ha Layng lson osc Age Relative Confidence Final AW Initia Corma S. no Age T stage Site/Subsite Can Risk Interval Management Complications l orbidity ck. Death’ (99% CI) nt Index Lahane CACF Gr LAR 1 MR 56 r T3NOMO 11 (6.01 - 62.40) 3 None

19.37 VLS+FOB (SiPra;brac)LAR 2 MO T4aNOMO 2 None gra reg tag 57 7 13.37 (4.81-37.22) VLS+FOB

How to cite this article: Francisco O V, Cecil B R, Aaron S, Shannan C C. Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper 0072 Airway Cancer. Glob J Oto 2018; 14(3): 555888. DOI: 10.19080/GJO.2018.14.555888 Global Journal of Otolaryngology

Yes (Anxiety, Effi 3 BJ 68 T3N2bM 0 5 633 2 Awk Trach motion, SOB (Psi-us during Each) (3.07 -132)

Papraillf(s)LAWN 4 WR 43 T4aNOMO 6 923 (334-2220) 3 Awk Trach None graregtetti Yes (SOB during LAIR tads, motion and 5 BC 56 T4aNOMO (6.01-62.40) 2 Awk Trach faiRa9ttti4 bleating tebre 19.37 access the AW) U1R 6 GR 52 T3N1M0 5 338 4 Awk Trach None (Buyaghlci (3.07-132) LAIR JC T3N3M0 9 (6.01 - 52.40) 2 None

7 67 19.37 VLS+FOB (aCraPtc€01)EfH T4bN2cIA Yes (SOB during 8 DH 58 3 Awk Trach 0 be procedure) usapraEktf(s) (Psi- 7 13.37 (4.81-37.22) EAR 9 MW 68 T4aNDM 1 8 (6.01 - 52.40) 2 None (Traregtati 19.37 VLS+FOB LAIR 10 58 T3N3M0 2 None

PD 7 13.37 (4.81 - 37.22) VLS+FOB (9-,PraEltat)LAIR 11 CV 53 T3N1M0 2 None

7 13.37 (4.81 - 37.22) VLS+FOB PuPtaiiltat) None Rescue a ET tube due b 12 T4aNDM 1 LAIR 6 923 (3.84-2220) 2 (Notablesmall size to of Pass the tracheal lumen > FE 70 VLS+FOB at frst ty) VLS FOBI intub (Verece) 13 58 T4N2cM 1 LAR 9 (3.84-2220) 3 None

PE (Swagbitenris 19.37 VLS+FOB None Rescue (Anesth ET c blood, compessit 14 WC 62 T31040 4 4.4 2 sxs and trismus THYFCOFTC ¢A5-7.90) VLS+FOB at frst try) > VLS FOBI intub 15 WC 62 T3N3M0 4 4.4 2 None

THYFCDPTCLAR ¢A5-7.90) VLS+FOB None Rescue (2nd intub > VLS 16 HS 54 T2N2bM1 (Soacpu 11 (6.01 - 62.40) 2

seSirrus) 19.37 VLS+FOB try) FOBI intub frst Discussion landmarks are distorted or absent due to tumor progression.

standard by American Society of Anesthesiologists task force on Elective fiberoptic intubation is a technique considered The ultimate fear of an anticipated difficult intubation is “failure to intubate,” and the principal factor contributing to failed anticipated, such as in the aforementioned cases [11]. However, This situation is not uncommon in advanced oral cavity, pharynx, management of the difficult airway when a challenging airway is tracheal intubation is the inability to view the vocal cords [7]. larynx, thyroid gland, neck metastatic cancer, post irradiated neck, laryngeal deviation or previous surgery where the normal FOBI is limited by three important factors. First, the technique is mostly dependent on FOBI user experience and confidence,

How to cite this article: Francisco O V, Cecil B R, Aaron S, Shannan C C. Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper 0073 Airway Cancer. Glob J Oto 2018; 14(3): 555888. DOI: 10.19080/GJO.2018.14.555888 Global Journal of Otolaryngology and therefore, outcome is operator skill dependent. Secondly, Conclusion the position of the patient and the level of sedation contribute Even with a thorough clinical pre-anesthetic assessment, to the base of the tongue, epiglottis, and pharyngeal soft tissue complications cannot be predicted in this subset of patients. falling to the back of the pharynx obstructing the airway [12,13]. Tracheotomy is ideally performed in a previously intubated Lastly, it is not infrequent for the operator to struggle patient whose airway is secure when compared to awake to recognize laryngeal landmarks resulting from the limited tracheotomy under local anesthesia. Sudden changes like impending airway obstruction in a stable patient may require an secretions or blood obscuring the optics. The described expedited surgical procedure, increasing risks for complications. narrow view from the flexible bronchoscope and potential technique is particularly useful when the narrow view limitation can be compensated by using the panoramic view from the Videolaryngoscopy combined fiberoptic bronchoscopic assisted VLS in which the 60o blade lifts the base of the tongue and providing an excellent view of the airway anatomy. VLS/ endotracheal tube placement is easily performed and efficient, pharyngeal soft tissue, yielding a much broader frontal view of the epiglottis, arytenoids, and aryepiglottic folds. The ultimate management in hospital setting. The equipment is readily FOBI is a useful method for professionals involved in airway available in a majority of hospitals. Although this technique VLS over the area of interest while having the operator to freely requires an assisting hand, it is considered easier to perform result is the additional visualization from the FOB assisted by and irrigation channel is also available for usage during the of time for intubation, and potentially saves the patient from manipulate and advance the tip of the fiberscope. A suction than fiberoptic intubation alone, requires the same amount intubation. In a large randomized clinical trial the median time emergent or urgent airway procedures which carry increased for Videolaryngoscopy intubation was 3 minutes [14]. Overall, risk of complications. in our series none of the cases required a second pass or took longer than 2 minutes. However, three cases we changed to a References longer VLS blade and three cases we removed the blade to clear 1. Emergency Airway Registry (NEAR) Investigators. Improved glottic excessive secretions over the optics. exposureBrown CA, with Bair the AE, Video Pallin Macintosh DJ, Lauren Laryngoscope EG, Wall RM in adult (2010) emergency National department tracheal intubations. Ann Emerg Med 56(2): 83-88. However, these changes did not add increased overall time to intubation. It is known that awake tracheotomy in cancer 2. ® video- extending to the larynx is not exempt from complications and laryngoscopy versus direct laryngoscopy for endotracheal intubation: aGriesdale systematic DE, review Liu D, and McKinney meta-analysis. J, Choi CanPT (2012) J Anesth Glidescope 59(1): 41-52. can pose a sudden major risk to the airway due to many factors. 3. in the Emergency Department: Glidescope Videolaryngoscopy pulmonary function and low respiratory reserve. When ComparedMosier JM, Stolzto Direct U, Chiu Laryngoscopy. S, Sakles JC (2012) J Emerg Difficult Med 42(6): Airway 629-634. Management Typically, these patients are smokers with COPD, compromised performing an expeditious surgical airway procedure there are 4. unique risks such as unexpected coughing, anxiety, panic, motion GlideScope for rigid bronchoscopic placement of Dynamic (Y) stent. or inability to maintain a supine position, inability to maintain AnnYarmus Thorac L, Gilbert Surg 94(1): C, Akulian 308-310. J, Feller Kopman D (2012) Novel use of neck a still under extension, possibility of distorted anatomy 5. or associated uncontrolled comorbidities. These unique risks associated to comorbidities can result in oxygen desaturation, Yents SM (2002) Predicting difficult intubation-worthwhile exercise or 6. pointless ritual? Anaesthesia 57(2): 105-109. bleeding, pneumothorax, sudden loss of ventilation, seeding tumor in the peristomal access, and death. We included in Table Shiga T, Wajima Z, Inoue T, Sakamot A (2005) Predicting Difficult Intubation in Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance. Anesthesiology 103(2): 429-437. risk of death. Anaesthesia 39(11): 1105-1111. 1 Charlson Age Comorbity Index “CACI” and respective relative 7. Cormack RS, Lehane J (1984) difficult tracheal intubation in obstetrics. 8. These complications are not always mentioned in the Airway Teaching Method. Anesthesiology 101(5): 1252. Doyle DJ (2004) GlideScope-assisted Fiberoptic Intubation: A New 9. Altman KW, Waltonen JD, Kern RC (2005) Urgent Surgical Airway high morbidity and mortality due to the potential existing risks literature [9,15,16]. For these reasons, one should keep in mind Intervention: A 3 Year County Hospital Experience. Laryngoscope when performing awake tracheostomy on these patients. If 115(12): 2101-2104. the anatomy is favorable the ideal is to perform tracheotomy 10. in patients under controlled conditions who are previously intubated and whose airway is already secure. There were 564-565.Vitin AA, Erdman JE (2007) A difficult airway case with GlideScope- assisted fiberoptic intubation. Journal of Clinical Anesthesia 19(7): any randomized controlled trials comparing the frequency of 11. seeding tumor due to endotracheal intubation on larynx cancer Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, et al. (2013) patients in the literature. However; Esteller et al discussed Updated Report by the American Society of Anesthesiologists Task Practice Guidelines for Management of the Difficult Airway: An stomal recurrence and tumor seeding of the tracheostomy site Force on Management of the Difficult Airway. Anesthesiology 98(5): 12. ®- emergent awake tracheostomies. 1269-1277. [17]. Apparently, this risk can be potentiated by expedited or AnaesthesiaXue FS, Li CW, 61(10): Zhang 1014-1015. GH, Li XY, Sun HT, et al. (2006) GlideScope assisted awake fiberoptic intubation: initial experience in 13 patients.

How to cite this article: Francisco O V, Cecil B R, Aaron S, Shannan C C. Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper 0074 Airway Cancer. Glob J Oto 2018; 14(3): 555888. DOI: 10.19080/GJO.2018.14.555888 Global Journal of Otolaryngology

13. Crosby ET, Cooper RM, Douglas MJ, Doyle DJ, Hung OR, et al. (1998) the 15.

Moore MS, Wong AB (2007) GlideScope intubation assisted by unanticipated difficult airway with recommendations for management. 16. fiberscope. Anesthesiology 106(4): 885-886. 14. CanLascarrou J Anaesth JB, Boisrame45(8): 757-776. Helms J, Bailly A, Le Thuaut A, Kamel T, et al. impeding airway obstruction. Otolaryngology Head and Neck Surg 136(5):Yuen HW, 838-842. Loy AH, Johari S (2007) Urgent awake tracheotomy for Group. Video Laryngoscopy vs Direct Laryngoscopy on Successful (2017) for the Clinical Research in Intensive Care and Sepsis (CRICS) Esteller E, Agüero A, Martel M, López M, Quer M, et al. (2014) Stomal recurrence in head and neck cancer patients with temporary First-Pass Orotracheal Intubation among ICU Patients. A Randomized 17. Clinical Trial. JAMA 317(5): 483-493. tracheostomy. Auris Nasus Larynx 41(5): 467-470.

This work is licensed under Creative Commons Attribution 4.0 License Your next submission with Juniper Publishers DOI: 10.19080/GJO.2018.14.555888 will reach you the below assets • Quality Editorial service • • Reprints availability Swift Peer Review • E-prints Service • • Global attainment for your research Manuscript Podcast for convenient understanding • Manuscript accessibility in different formats ( Pdf, E-pub, Full Text, Audio) • Unceasing customer service

Track the below URL for one-step submission https://juniperpublishers.com/online-submission.php

How to cite this article: Francisco O V, Cecil B R, Aaron S, Shannan C C. Videolaryngoscope Assisted Fiberoptic Bronchoscopy for Difficult Intubation in Upper 0075 Airway Cancer. Glob J Oto 2018; 14(3): 555888. DOI: 10.19080/GJO.2018.14.555888