|Year : 2016 | Volume
| Issue : 3 | Page : 151-154
Successful management of difficult airway: A case series
Balraj Hariharasudhan, Rajesh S Mane, Vandana A Gogate, Mallikarjun G Dhorigol
Department of Anaesthesiology, Jawaharlal Nehru Medical College, KLE University, Belagavi, Karnataka, India
|Date of Web Publication||14-Sep-2016|
Rajesh S Mane
Department of Anaesthesiology, Jawaharlal Nehru Medical College, JNMC Campus, KLE University, Nehru Nagar, Belagavi - 590010, Karnataka
Source of Support: None, Conflict of Interest: None
Management of difficult airway is widely recognized as one of the important tasks of an anesthesiologist. The problems related to it are known to be primary causes of life-threatening consequences. Herewith, we present a case series of difficult airway scenarios managed successfully with different techniques and airway gadgets. The following cases were managed successfully with appropriate airway techniques: 1) Ludwig's angina for drainage with awake fiberoptic intubation, 2) temporomandibular joint (TMJ) ankylosis for bilateral gap arthroplasty with fiberoptic intubation, 3) burn contractures for the release managed with intubating laryngeal mask airway (ILMA). Airway management is one of the vital aspects of clinical care provided by an anesthesiologist. The airway-related complications have significantly decreased due to better knowledge, skills of the anesthesiologist, and an array of airway gadgets. The three case scenarios of difficult airway were successfully managed with the appropriate airway gadgets suitable for each case without any untoward complication. Most airway problems can be solved with available gadgets and techniques, but clinical judgement borne of experience and expertise is crucial in implementing the skills in any difficult airway scenario.
Keywords: Difficult airway, fiberoptic, intubating laryngeal mask airway (ILMA), intubation
|How to cite this article:|
Hariharasudhan B, Mane RS, Gogate VA, Dhorigol MG. Successful management of difficult airway: A case series. J Sci Soc 2016;43:151-4
| Introduction|| |
Managing a difficult airway has always been a major concern to an anesthesiologist. Airway-related complications are one of the commonest causes for anesthesia-related morbidities and mortalities. Poor airway management has been recognized as a serious patient safety concern for almost three decades, highlighting the need for careful airway assessment before the induction of anesthesia. While improvements in patient monitoring, airway devices, and clinical protocols and training have reduced the risk associated with a difficult airway, these changes have not reduced the incidence of unexpected difficult airway in clinical practice.  Herewith, we present a case series of difficult airway scenarios managed successfully with different techniques and airway gadgets.
| Case reports|| |
Case scenario 1
A 45-year-old female patient presented with complaints of oral and neck pain and difficulty in swallowing for 3 days. She reported with progressive swelling in the neck and inability to open her mouth. An infected third molar had been extracted 3 days before the present illness. In addition, she complained of difficulty in breathing when in the supine position. Her mouth opening was two fingerbreadth with limited neck flexion and extension. She was diagnosed to have Ludwig's angina and was posted for incision and drainage. An awake fiberoptic intubation was planned.
The patient was shifted to the operating room, given a semi-propped up position and all standard monitors were attached. Bilateral superior laryngeal nerve block with 2 mL of 2% lignocaine was given at the greater cornu of the hyoid bone and an intratracheal injection of 2% lignocaine was instituted. Nasal decongestant drops were instilled to minimize nasal airway bleed. Just before the fiberoptic bronchoscope (FOB) was inserted, two puffs of 10% lignocaine spray was sprayed onto the posterior pharyngeal wall.
FOB was checked and a 6.5 mm internal diameter (ID) cuffed endotracheal tube (CETT) was threaded over it. The fiberscope was inserted into the right nostril and after negotiating through the upper airway and the vocal cords, the trachea was entered and the carina was visualized. The endotracheal tube (ETT) was then railroaded over the bronchoscope into the trachea. The tube was confirmed by fiberoptic viewing of tube tip inside the trachea, inability to vocalize, and end-tidal carbon dioxide. The patient withstood the procedure well.
Anesthesia was then induced with propofol 2 mg/kg and vecuronium 0.1 mg/kg and maintained with sevoflurane and fentanyl. The patient parameters were monitored throughout the procedure. The trachea was extubated after adequate reversal was confirmed. A rescue plan with supraglottic airway devices such as I-gel can be considered if the planned modality to secure the airway had to fail.
Case scenario 2
A 3.5-years-old boy, weighing 15 kg, presented with limited mouth opening. He was diagnosed as a case of bilateral temporomandibular joint (TMJ) ankylosis and planned to undergo bilateral gap arthroplasty with bilateral coronoidectomy under general anesthesia. In preanesthetic assessment, the child was otherwise healthy with no comorbid conditions. The airway examination revealed a total ankylosis with complete immobility of the mandible. The mouth opening (interincisor gap −3 mm) was severely reduced and Mallampati class was Grade 4 with retrognathia.
All laboratory investigations were within normal limits. The parents were counselled regarding the nature of difficult airway and its management options, namely fiberoptic intubation and tracheostomy. Informed consent was taken from the child's parents.
In the preoperative area, two drops of nasal vasoconstrictors (xylometazoline) was instilled in each nostril. The patient was premedicated with intramuscular (IM) ketamine 50 mg injection plus glycopyrrolate 0.1 mg injection. In the operating room, standard American Society of Anesthesiologists (ASA) monitoring such as electrocardiogram (ECG), noninvasive blood pressure (NIBP), and SPO2 were attached. A 22-gauge intravenous (IV) cannula was placed on the right hand and Ringer's lactate started as a maintenance fluid. Inhalational induction with sevoflurane in 100% oxygen was commenced. A 4 mm ETT was introduced through the left nostril into the nasopharynx and used as a nasopharyngeal airway. The Jackson-Reed circuit was connected to the airway and the concentration of sevoflurane was gradually titrated, preserving spontaneous breathing. Fiberoptic scope with a 4 mm ETT threaded over it was then passed through the opposite nostril. The vocal cords were visualized and 1 mL of lignocaine was injected through the port over it and FOB was advanced into the trachea to identify the carina. The endotracheal tube size 4 mm was then advanced over the fiberopticscope into the trachea. The ETT was then connected to the anesthetic breathing circuit and the correct placement of the tube in the trachea was confirmed by end-tidal carbondioxide (ETCO2) and bilateral chest auscultation. Fentanyl 30 mcg injection and vecuronium 1.5 mg IV injection were administered and anesthesia was maintained with sevoflurane 0.6% in 40:60 oxygen and nitrous oxide. At the end of the surgery, neuromuscular blockade was reversed and the child was extubated awake with intact airway reflexes. Retrograde intubation technique or establishing a surgical airway were other modalities that could have been employed, if the planned method of securing the airway had to fail in this patient.
Case scenario 3
A 48-year-old female patient with post-burn contracture (PBC) of face, neck, and chest was posted for PBC release. Her mouth opening was adequate with a Mallampati class 3. The patient had a severely restricted neck extension because of the burn contracture. Airway management was planned with an intubating laryngeal mask airway (ILMA). The patient was premedicated with fentanyl 2 mcg/kg and midazolam 0.05 mg/kg. Anesthesia was induced with propofol 2.5 mg/kg and a size 3 ILMA, lubricated with 5% lidocaine ointment was inserted. After inflation of the laryngeal mask airway (LMA) cuff and confirming adequate ventilation by proper positioning, neuromuscular blockade was achieved with vecuronium 0.01 mg/kg. A FASTRACH size 7 ETT accompanying the ILMA was inserted through the ILMA and advanced into the trachea. The ILMA was removed once the position of the ETT was clinically confirmed by the presence of bilateral air entry and capnography. The trachea was extubated after adequate reversal with intact airway reflexes. FOB facilitated tracheal intubation would have been the best alternative modality to rescue the airway if intubation was not achieved with LMA Fastrach.
All patients were hemodynamically stable throughout the airway management scenarios. Both the intraoperative and postoperative periods were uneventful with no significant desaturation episodes requiring active intervention.
| Discussion|| |
A difficult airway is a clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation, tracheal intubation, or both.  Common causes for anticipated difficult airway may include syndromes such as Pierre-Robin, Treacher-Collins, Downs, Klippel-Feil, tumors, trauma, and burns, while unanticipated difficult airway may include infections, abscess, Ludwig's angina, rheumatoid arthritis, obesity, and acromegaly. Many devices and techniques are now available to circumvent the challenges encountered with difficult airway using conventional laryngoscopy. Endotracheal tube guides, different types and sizes of laryngoscope blades, supraglottic airway devices, lighted stylets, rigid video laryngoscopes, and indirect fiberoptic laryngoscopes are few options over an exhausting list.
Supraglottic airway devices such as LMA have been a revolution and a first go option in case of an unanticipated difficult airway scenario.  The LMA is an important option within the ASA difficult airway algorithm, and has been proved to be a highly useful aid to fiberoptic intubation with ETT. 
Fiberoptic intubation under spontaneous ventilation remains the choice, in any anticipated difficult airway, considering that laryngoscopic intubation may be difficult and may possibly worsen any difficult airway scenario.  Awake fiberoptic intubation has recently gained acceptance with good intubating conditions found in awake patients because they can assist in clearing their own secretions, phonating, or panting. 
Shaik et al. (2014), in a case report on anesthetic management of Ludwig's angina concluded that awake fiberoptic intubation under topical anesthesia is sophisticated and a less invasive method of securing airway in patients with deep neck infection. 
Kang et al. (2013) presented a case report of managing a TMJ ankylosis posted for spine deformity secondary to ankylosing spondylitis with minimal mouth opening. Awake fiberoptic intubation was conducted successfully and they concluded that fiberoptic bronchoscopic nasotracheal intubation conducted under conditions of awareness reduces the risk of developing hypoxia and pulmonary aspiration and eventually the necessity to perform an emergency tracheostomy in situations of such difficult airway scenarios. 
The ILMA is another device used in cases of difficult laryngoscopy and is routinely used as a conduit for intubation. The ILMA is inserted to a depth where it rests upon the supraglottic laryngeal structures of the upper airway. A seal is produced when the mask is inflated, allowing the patient to either breathe spontaneously or be ventilated manually via the ILMA tube. The use of ILMA (FASTRACH) allows for maintenance of optimal oxygenation and ventilation and provides a seamless bridge to tracheal intubation. 
Brian et al. suggested that tracheal intubation with ILMA was easier in the abnormal than in the normal airway, because the high anterior larynx associated with Cormack and Lehane grade III and IV facilitated a better alignment of the ILMA and glottic aperture.  Langeron et al. compared ILMA with FOB in a hundred difficult airway patients and concluded that the success rate of tracheal intubation and procedure duration were comparable between both the devices but in an unanticipated difficult airway scenario, the ILMA provides rescue ventilation in 94% compared to 50% offered by the FOB.  ILMA could thus be considered as an interesting option in unanticipated difficult airway management, as is the LMA in difficult airway algorithm.
Hence, all the supraglottic airway gadgets and bronchoscopes not only offer a rescue option in various difficult airway scenarios but can be a part of the primary and sole airway management plan in any clinical situation, unless a definitive secure airway is warranted.
| Conclusion|| |
Choosing an appropriate technique for management of both anticipated and unanticipated difficult airway should be executed wisely and precisely with ideal airway devices. Thorough knowledge and skill in all the techniques should be mastered as mismanaged difficult airways can lead to disastrous consequences.
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Conflicts of interest
There are no conflicts of interest.
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