Air-Q®sp-assisted awake fiberoptic bronchoscopic intubation in a patient with Ludwig's angina.

Abstract

A drastic, progressive gangrenous cellulitis of the soft tissues of the deep neck and mouth floor was described in 1836 by the German surgeon Karl Friedrich Wilhelm von Ludwig [1]. Current medical care practices have meant that Ludwig’s angina is rarely seen. However, once the disease process is underway, there is a serious risk of sudden death due to airway obstruction. We describe the successful management of a case of Ludwig’s angina and provide details of awake fiberoptic bronchoscope (FOB) intubation using the Air-Q Ⓡ sp as a conduit. A 57-year-old, 80 kg man presented complaining of a 3 day history of mouth and neck pain, dyspnea, and dysphagia. The patient had no recent history of dental treatment, but had a medical history of gout, hypertension for 10 years, and a mild cerebral stroke 8 years previously. Laboratory tests revealed acute kidney injury combined with severe dehydration. Despite the hospitalized treatment for 2 days, his symptoms worsened and he began to exhibit the features of Ludwig’s angina. Neck computed tomography (CT) showed severe swelling of the left peritonsilar region with parapharyngeal space-occupying lesions, the aryepiglottic folds with obstruction of the left pyriform sinus were suggestive of a deep neck infection. The patient was scheduled to undergo emergency intubation ahead of surgery. The patient underwent hemodialysis to correct his renal and hemodynamic conditions prior to the procedure. He was febrile (a tympanic temperature of 39 o C), a heart rate of 115 bpm, a respiratory rate of 25, and blood pressure of 150/90 mmHg. The extent of mouth opening was slightly restricted with an inter-incisor gap of 2.5 cm. Tracheostomy was considered, but it was rejected because of concerns over the reduction in the patient’s cricothyroid space caused by the swelling, the limited extension and shortness of the neck with vague landmarks. Awake FOB intubation was selected as the safest option. The necessity of the procedure was explained to the patient and written informed consent was obtained. Because of the patient’s status, no premedication was administered. It was difficult to effectively administer nebulized drugs, so topical 4% lidocaine drops and a 10% lignocaine spray puff was used. The FOB (outer diameter of 3.5 mm) was fitted with a size 7.0 endotracheal tube (ET). After preoxygenation (SpO2 was 98%) and meticulous suction of oral secretions, the FOB tip was gently introduced into the oral cavity with the full cooperation. The vocal cords were visible, but it was hard to move past them because of their swollen and distorted anatomy, and moving the tongue disturbed the progress, thereby stopping the FOB tip. For the second attempt, a lubricated Air-Q Ⓡ sp size 3.5 (Cookgas LLC, St. Louis, USA) was gently inserted without hindrance, and a bite block was inserted through the tube of the Air-Q Ⓡ sp after removing the red-color coded connector. The prepared FOB and ET were inserted using the Air-Q Ⓡ sp as a conduit; the FOB tip was able to easily pass over the vocal cords and into the trachea. There were no difficulties in removing the Air-Q Ⓡ sp after intubation. Successful tracheal intubation had been achieved while maintaining spontaneous ventilation. The patient was admitted to the ICU for intensive medical care. The following morning, the patient was stable but neck CT showed the deep neck regions were aggravated. Elective surgery to incise and drain the lesions was performed. Surgery and postextubation recovery was uneventful. Clinical recovery was slow, with a persistent fever that lasted until the fifth day of