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Editorial Case Report Journal of Anaesthesia and Critical Care Case Reports 2017 Jan-Apr;3(1):22-24 Ventilating Bougie Guided Flexo-metalic Tube Intubation With Airtraq- Not A Technique Of Choice? Sunil Chapane¹, Sweta Salgaonkar¹, Salman Tadvi¹ Abstract Introduction: Airtraq, a type of video-laryngoscope used for endotracheal intubation requires less manipulation of airway axis like neck extension. We report a case of awake Airtraq assisted oral intubation in a 55 year old female posted for calvarial bone graft on face and microstomia repair having an inadequate mouth opening. We had a failed attempt of advancement of flexometalic tube over ventilating bougie with Airtraq. We think a flexometallic tube with Airtraq is not the right combination but it needs further evidence to prove. Keywords:Difficult airway, Awake Intubation, Airtraq, Ventilating Bougie.

Introduction side of face for soft tissue loss and exposed loss and bone exposure. Patient needed Old faciomaxillary trauma may pose as bone. This patient had lost left nostril due regular nasopharyngeal airway dilatation to difficult airway for anesthetic management. to free flap cover. maintain patency of her right nostril while Awake fiberoptic intubation has been the We planned awake oral intubation using left nostril lost an under-flap. gold standard for airway management of Airtraq with flexometallic tube in She had undergone facial flap thinning anticipated difficult airway cases [1,2,3]. microstomia with single right nostril for under sedation and tumescent anesthesia. Airtraq is an indirect optical video- face bone graft and microstomia repair. Patient had no history of any medical laryngoscope which provides optimum Airtraq with flexometallic tube posed illness, allergy or addictions. glottic view without manipulating all three difficulty in advancement of tube over On pre-operative airway examination, airway axis which are required in ventilating bougie so we had to use Mallampati score was class IV with conventional direct laryngoscopies. Airtraq polyvinyl chloride (PVC) ET tube after inadequate mouth opening with inter- can be used for endotracheal intubation of consulting the surgeons. incisor distance2 cm and 4 cm horizontal difficult airway cases where mouth opening dimension due to encroachment of flap on is restricted [4,5,6]. Awake Airtraq Case Report left angle of mouth (Fig.1). Right nostril intubation can be performed in difficult Fifty-two years old female weighing 48kg was patent, other airway findings were airway cases after adequate preparation of with a history of facial deformity following normal. Neck anatomy was assessed for airways. Flexometallic tubes are preferred pan facial trauma due to vehicular accident feasibility of topical airway blocks. in maxillofacial surgeries because of their was posted for calvarial bone graft for Laboratory investigations, chest X-ray and kink resistant nature and flexibility in fixed frontal bone defect and mouth ECG were within normal limits. General position [7,8]. Due to the flexibility of reconstruction surgery. Patient had a and systemic examination was normal. flexometallic tube, it needs to be guided history of previous tracheostomy during Patient was counselled for awake oral over stylet or ventilating bougie for acute pan-facial trauma for airway intubation. endotracheal intubation [9]. protection and consequent surgeries. Patient was informed about the anesthetic We had a patient of old facial trauma Patient had undergone bilateral zygoma, plan, surgical procedure and a written following vehicular accident with pan facial left frontal bone and left mandible plating informed consent was obtained. We fractures undergone open reduction under general anesthesia followed by free anticipated difficulty in mask ventilation internal fixation and free radial flap on left radial flap on left side of face for soft tissue due to deformed anatomy with single nostril and difficult intubation due to 1Dept. of Anesthesia, Seth G S Medical College and restricted mouth opening. For K E M Hospital, Parel, Mumbai. cosmetic purpose, surgeons advised not to open angle of mouth under local Address of Correspondence Dr. Sunil Chapane anaesthesia (LA). Patient had a scar Dept. Of Anesthesia, First Floor, Old Building, from previous tracheostomy and a re- Seth GSMC and Kem Hospital, Parel, Mumbai -12. tracheostomy would have its own Email : [email protected] complications, therefore, we planned Dr. Sunil Chapane Dr. Sweta Salgaonkar Dr. Salman Tadvi awake Airtraq guided © 2017 by Journal of Anaesthesia and Critical Care Case Reports| Available on www.jaccr.com | flexometallic intubation. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License Plan A was awake oral (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. intubation using Airtraq

Figure 1: Patient with difficult airway having microstomia and single nostril due to Figure 2: Airtraq with different dimensions encroached free flap with flexomatallic tube after adequate Cormac Lehane Grade I. Flexometallic Tracheostomy is an invasive procedure and airway preparation under sedation. endotracheal tube (ETT) was tried to has its own complications and patient had Plan B was opening of microstomia under advance into trachea by forward force and previously undergone tracheostomy during local anesthesia and sedation and Airtraq rotatory movement of tube over ventilating acute trauma for multiple facial fractures for guided intubation under general anesthesia. bougie with stylet but advancement of the airway maintenance and surgeries. Plan C was elective tracheostomy under LA flexomatallic ETT over Airtraq was not Awake blind nasal procedure was avoided to and sedation followed by general anesthesia. possible. So, we removed flexometalic tube prevent trauma to the nasal cavity which Airway was prepared with topical anesthesia and ventilating bougie without removing might compromise her only nostril and also with10ml of 4% viscous lignocaine gargles Airtraq from mouth, 7mm cuffed PVC because of the possibility of injury to airway and 2ml of 4% lignocaine nebulization in endotracheal tube was inserted through due to blind technique. preoperative area. The patient was given Airtraq channel into trachea after consulting Due to small dimensions of Airtraq, it can intramuscular inj.Glycopyrolate 0.4 mg30 the operating surgeons. Endotracheal be used in cases of restricted mouth min prior to going inside the operating intubation confirmed by clinical opening. Also, preformed curvature of theatre as anti-sialogouge. Once inside, examination and capnography. Airtraq airway axes alignment is not routine monitors like pulse oximeter, Throughout this procedure patient was necessary and intubation is possible without electrocardiogram (ECG), non-invasive comfortable, well sedated, awake and neck extension. Due to overlying buccal blood pressure (NIBP), end tidal carbon maintained saturation. Patient was flap, tissue was not stretchable so dioxide (ETCO2) and temperature were anaesthetized with propofol and muscle improvement in mouth opening under attached. All baseline parameters were relaxant was given. Post-induction check anesthesia was not expected. As patient was normal. Midazolam 1mg, fentanyl 100mcg laryngoscopy was done to see the glottis posted for mouth reconstruction surgery given intravenously after securing view which was Cormac Lehane Grade IIb along with frontal bone graft, flexometallic intravenous line. Sedation was maintained but mouth opening was less so introducing tube was selected for flexibility position of with dexmeditomedine infusion at tube would have been difficult obscuring tube so surgeons can work around the tube. 0.5mcg/kg/min. Bilateral superior laryngeal glottic view with conventional laryngoscopy. Flexometallic tube is difficult to pass nerve and glossopharyngeal also blocked by Whole surgical procedure was uneventful. through cords without bougie or stylet. So, injecting 2% lignocaine 2ml on each side. Patient was extubated after she was fully flexometallic tube with ventilating bougie is Thus, oral, oropharyngeal and supraglottic awake and full reversal of muscle relaxant preloaded in a channel next to the optical structures were anaesthetized. Trans- was obtained. pathway. Ideally Airtraq should be in tracheal injection at cricothyroid membrane midline, but in this case, as the left side of was given with 2ml of 4% lignocaine and Discussion angle of mouth was encroached upon by patient was encouraged to cough to In our case, patient had inadequate mouth flap, introduction of Airtraq in the midline anaesthetize the infra-glottic structures. opening with compromised nasal anatomy oropharynx was slightly difficult. Cuffed 7mm flexometalic tube was showing small snares, constricted nasal During intubation attempt, ventilating preloaded with ventilating bougie on No. 2 cavity and awake fiber-optic intubation is bougie with flexometallic tube did not green colored Airtraq whose dimensions done preferably through nose than mouth. advance through vocal cords after were adequate for oral intubation in this Due to all these problems and non- visualizing glottic view by Airtraq due to case (Fig.2).We introduced this assembly availability of fiber-optic bronchoscope, we excessive flexibility of tube. Tube made up orally after confirming adequate sedation decided to go for awake Airtraq oral of polyvinyl chloride material can be and topical anesthesia. Glotticview was intubation. advanced over Airtraq without any

23 | Journal of Anaesthesia and Critical Care Case Reports | Volume 3 | Issue 1 | Jan-Apr 2017 | Page 22-24 Chapane S et al www.jaccr.com difficulty. inter-incisor distance and 30mm of opening during laryngoscopy which was Valmiki et al. also had same difficulty with horizontal dimension is required for true in our case. flexometallic tube over Airtraq during awake intraoral introduction of Airtraq. Airtraq So, we propose that flexometallic tube with intubation in patient with large thyroid needs to be inserted in the midline for ventilating bougie and Airtraq is not a posted for thyroidectomy [10]. excellent glottic view and easy introduction technique of choice for intubation as it is of ETT. Bougie guided flexometallic tube difficult to advancethe tube over Airtraq due Conclusion awake intubation using Airtraq may be to excessive flexibility of tube and stiffness Optimum airway preparation and adequate difficult due to unsuccessful advancement of of stylet of ventilating bougie. Although, sedation is necessary for patient cooperation tube over Airtraq. Flap tissue is less more evidence is needed to recommend that during awake intubation. Airtraq guided compliant compared to normal buccal above combination is not advisable at all. awake intubation can be done in difficult tissue, therefore, it is not expected that it airway cases [4,5,6]. Minimum of 18mm of will stretch and improve in the mouth References 1. Ezri T, Szmuk P, Warters RD, Katz J, Hagberg C. Difficult airway tracheal intubation. Anaesthesia 2008; 63:182–8. management practice patterns among anaesthesiologists practicing in the 6. Dimitrion V,Kouny A,Haribi M. Airtraq optical laryngoscope for tracheal United States: have we made any progress? J Clin Anesth 2003;15:418–22. intubation in giant neck lipoma with additional risk factors of anticipated 2. Dimitriou V, Iatrou C, Douma A, Athanassiou L, Voyagis GS. Airway difficult airway. M.E.J.Anaesth. 2015;23(3). management in Greece: a nationwide postalsurvey. Minerva Anestesiol 7. Brusco L Jr,Weissman C. Pharyngeal obstruction of a reinforced 2008;74:453–8. orotracheal tube.Anesth Analg 1993;76:653-4. 3. Kristensen MS, Møller J. Airway management behaviour, experience and 8. Eipe N,Choudhrie A,Pillai AD,Choudhrie R.Neck contracture release and knowledge among Danish anaesthesiologists– room for improvement. Acta reinforced tracheal tube obstruction.Anesth Analg 2006;102:1911-2. Anaesthesiol Scand 2001;45:1181–5. 9. Martens P. Persistent narrowing of an armoured tube. Anaesthesia 1992; 4. Saracoglu KT, Eti Z, Gogus FY. Airtraq optical laryngoscope: advantages 47:716-7. and disadvantages. Middle East Journal of Anasethesiology 2013;22(2):135-140 10. Avad VN,Kotak N,Pajai.NAirway management using Airtraq in large thyroid mass surgery. Journal of Anaes. & Critical care case reports 5. Maharaj CH, Costello JF, Harte BH, Laffey JG. Evaluation of the Airtraq 2015;2:17-19. and Macintosh laryngoscopes in patients at increased risk for difficult

How to Cite this Article Conflict of Interest: Nil Chapane S, Salgaonkar S, Tadvi S. Ventilating Bougie Guided Flexo-metalic Tube Source of Support: None Intubation With Airtraq- Not A Technique Of Choice? Journal of Anaesthesia and Critical Care Case Reports Jan-Apr 2017; 3(1):22-24.