Year : 2021 | Volume
: 20 | Issue : 3 | Page : 232--234
Fiber-optic-assisted endotracheal intubation complicated by iatrogenic right main bronchus obstruction
Sanjay Kumar, Vaishali Waindeskar, Deepti Aggrawal
Department of Anaesthesiology and Critical Care, All Indian Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
Dr. Vaishali Waindeskar
Department of Anaesthesiology and Critical Care, All Indian Institute of Medical Sciences, Bhopal - 462 020, Madhya Pradesh
Several aids have been designed for helping anesthetist in managing the difficult airway. Oral carcinomas often distort the airway anatomy and present as difficult airway usually with restricted mouth opening. In these scenarios, elective nasotracheal intubation with fiberoptic is done to secure the airway as well as to provide the full surgical field to the surgeon. Vertically split nasopharyngeal airway is one of the popular aids used as a conduit to pass fiber-optic bronchoscope. Timely removal of the split nasopharyngeal airway is must and if missed, and pushed inside bronchus leading to iatrogenic complication.
|How to cite this article:|
Kumar S, Waindeskar V, Aggrawal D. Fiber-optic-assisted endotracheal intubation complicated by iatrogenic right main bronchus obstruction.Ann Afr Med 2021;20:232-234
|How to cite this URL:|
Kumar S, Waindeskar V, Aggrawal D. Fiber-optic-assisted endotracheal intubation complicated by iatrogenic right main bronchus obstruction. Ann Afr Med [serial online] 2021 [cited 2022 Aug 13 ];20:232-234
Available from: https://www.annalsafrmed.org/text.asp?2021/20/3/232/326189
For securing the difficult airway, aids such as gum-elastic bougie, classic laryngeal mask airway (LMA), McCoy laryngoscope, stylet, fiber-optic bronchoscope, percutaneous tracheostomy kit, intubating LMA, retrograde intubation kit, Combitube, light wand, and Bullard laryngoscope are often used.
The availability and expertise of using airway management- assisting devices are on the increase. There are several aids frequently used in its naive or modified form for helping anesthesiologists in managing a difficult airway such as vertically split nasopharyngeal airway (vs-NPA) is one of the popular aids which are used as a conduit to pass fiber-optic scope. A common practice is to use a vs-NPA as a conduit to avoid injury to the nasal mucosa and to reduce the fiber-optic bronchoscope-assisted intubation difficulties. An important step is to remove the vs-NPA as soon as the fiber-optic scope enters through vocal cords, and the endotracheal tube is pushed down inside the trachea. Varghese et al. compared the use of LMA with modified oropharyngeal airway and found that the success rate of single attempt intubation was 73.33%, in neonate and children. Nasopharyngeal airway (NPA) has been used by Abdel Basset et al., with a higher success rate. Mohammadzadeh et al. used NASAL-18 technique intubation and compared it with the conventional method. In the NASAL-18 technique, the endotracheal tube was inserted in nasopharynx up to mark 18. This method reduces the time needed for successful fiber-optic intubation. Kawamura et al. used processed nasal airway which they called “Osaka airway.” The airway had two cuts in line from top to tip which could be pulled off easily after the procedure. However, sometimes, it becomes a nightmare when it is not removed timely, i.e., before negotiating endotracheal tube.
We report a case of a 50 year male, American Society of Anesthesiologists Grade I patient, scheduled for surgery due to temporomandibular joint ankylosis and submucosal fibrosis. Written consent has been obtained from the patient. Airway examination revealed nil mouth opening, Mallampati grading Grade 4, and thyromental distance >6 cm. Hence, awake fiber-optic intubation was planned after proper airway preparation. The upper airway was anesthetized by gargling with 2% lignocaine viscous, 10% lignocaine spray, and intratracheal instillation of 2% lignocaine. The bilateral superior laryngeal nerve block was achieved by administering 1.5 ml of 2% lignocaine. After premedicating, adequately the patient was shifted to the operation table. NPA number 8 was cut along its entire length and was inserted through the right nostril so that it can be used as a conduit for bronchoscope. The patient was spontaneous ventilation, using another NPA through other nostril and connected to a breathing circuit. The flexible bronchoscope was negotiated and conduit through vs-NPA. Once the tip of bronchoscope was just above the vocal cord, injection propofol 2 mg/kg was given, and fiber-optic scope was passed through the vocal cord and endotracheal tube was railroad down the trachea. Ventilation was checked by bag ventilation and with capnography. Intravenous rocuronium 0.6 mg/kg was then given, and the patient was paralyzed. There was a sudden rise in peak airway pressure as the patient was put on ventilator. To find out the cause of, sudden increase in peak airway pressure, kinked breathing circuit, secretions plugging endotracheal tube and pneumothorax possibilities were ruled out. Again, manual ventilation done to check for bilateral air entry, but on the right side, air entry was decreased, and the patient was nebulized with B1 agonist; still, air entry did not improve on the right side. Meanwhile, we realized that vs-NPA is missing, and immediately, check bronchoscopy was done, not only to confirm the correct placement of the endotracheal tube but also to find out the missing vs-NPA. It was observed that the NPA which was used as a conduit for fiber-optic intubation was lodged in the right main bronchus.
What went wrong?
The entire length of the NPA was split to facilitate its removal after fiber-optic bronchoscopy at the desired time, but when the endotracheal tube was being railroaded over the bronchoscope, NPA was pushed along with the tube inside the trachea. Attempts were made to remove the vs-NPA, but it was not possible. We used flexible forceps provided with fiber-optic bronchoscope set, but it was unsuccessful. However, ventilation was possible, and both the lungs were getting ventilated.
Immediately, it was decided to continue with the surgery and cut was made on submucous fibrosis. After which, the mouth opening improved, making laryngoscopy possible with difficulty. Further surgical procedure was deferred for the time being, and decision was taken to go for rigid bronchoscopy for vs-NPA removal. After ventilating with 100% oxygen, the endotracheal tube was pulled out completely and rigid bronchoscope was inserted; a flange of the NPA was seen in the right bronchus. The flange was then grasped with optic forceps and removed. The patient was reintubated with oral endotracheal tube, injection hydrocortisone 200 mg was given, and further proceeding of surgery was performed successfully. After completion of the surgery, the patient was ventilated electively; because of excessive instrumentation of airway, the trachea was extubated on the next day without any complication.
There are several aids frequently used in its naive or modified form for helping anesthesiologists in managing a difficult airway. vs-NPA is one of the popular aids which are used as a conduit to pass fiber-optic scope. This is to be concluded that vs-NPA may be used to avoid nasal mucosa injury and facilitation of fiber-optic scope-assisted intubation, but timely removal of vs-NPA should be taken care off. It may be mandatory to assign this removal job to one of the team members dealing with difficult airway management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Pandey RK, Baruah U, Swetha S, Batra M, Punj J, Darlong V. Split nasopharyngeal airway as a conduit for oral fibre-optic intubation in a case of difficult airway. Saudi J Anaesth 2018;12:165-7.|
|2||Varghese E, Nagaraj R, Shwethapriya R. Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children. J Anaesthesiol Clin Pharmacol 2013;29:52-5.|
|3||Mohammadzadeh A, Haghighi M, Naderi B, Chaudhry A, Khan ZH, Rasouli MR, et al. Comparison of two different methods of fiber-optic nasal intubation: Conventional method versus facilitated method (NASAL-18). Ups J Med Sci 2011;116:138-41.|
|4||Kawamura S, Matsubara Y, Tamai Y, Fujiwara M, Kuri M, Amano M. The usefulness of the processed nasal airway for fibrescope guided nasotracheal intubation. Masui 2003;52:298-303.|