Airway topicalization during tracheal intubation using the Airtraq® laryngoscope in anesthetized patients

Abstract

To the Editor, It has been shown that topicalization of the larynx and trachea before intubation can prevent increases in arterial blood pressure during intubation, while simultaneously decreasing the incidence of coughing on emergence from general anesthesia. In clinical practice, the larynx and trachea in patients with normal airways are usually anesthetized with local anesthetic sprays using various devices under direct laryngoscopy or occasionally with a help of the fibrescope in patients with difficult airways. The Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) is a new disposable optical laryngoscope designed to facilitate orotracheal intubation in an uncomplicated or difficult airway. This device is easy to use and effective to facilitate tracheal intubation in anesthetized patients with either normal or difficult airways. However, when an Airtraq laryngoscope loaded with an endotracheal tube (ETT) is inserted into the anesthetized patient’s mouth, it is impossible to use a common atomizer to anesthetize the larynx and trachea because there is limited access to place the atomizer towards the targeted airway area. The MADett endotracheal tube mucosal atomization device (MADett, Wolfe Tory Medical Inc., Salt Lake City, UT, USA) is a new device designed to spray medications directly into the lungs via the ETT without interrupting ventilation in the intubating patients. It is a disposable 50.8 cm flexible cannula with memory that generates a 30 lm particle spray of injected medications. Recently, we have successfully combined the Airtraq laryngoscope and the MADett to provide topicalization of the glottis and trachea during tracheal intubation in anesthetized patients. After obtaining institutional ethics committee approval and written informed consent, 30 patients with ASA physical status I–II, aged 19–57 yr, and undergoing elective surgery under general anesthesia during May and June 2009 were included in this study. Exclusion criteria included a history of severe hepatic, renal, or coagulation diseases; gastroesophageal reflux; pregnancy; a known allergy to any of the study drugs; and a known or predicted difficult airway. After loading the ETT on the lateral channel of the Airtraq laryngoscope, the flexible cannula of the MADett was inserted into the ETT with its tip close to but not protruding beyond the distal end of the ETT. By mounting an elbow connector, the MADett was joined to the connector of the ETT. A 5-mL luer-locked syringe prefilled with a liquid solution of 2% lidocaine was connected to the distal end of the MADett (Fig. 1). After routine pre-oxygenation, anesthesia was induced with fentanyl 2 lg kg and propofol 2 mg kg iv, and neuromuscular block was produced with vecuronium 0.1 mg kg iv. With the patient’s head and neck placed in a neutral position, the Airtraq laryngoscope was inserted into the patient’s mouth over the tongue in the midline. Once the distal end of the Airtraq laryngoscope was positioned in the vallecula with the glottis in the centre of the viewfinder, the ETT was slightly advanced through the lateral channel of the Airtraq laryngoscope until its tip was placed immediately superior to the glottis. At that F. S. Xue, MD (&) J. H. Liu, MD X. Liao, MD Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China e-mail: fruitxue@yahoo.com.cn; profxuefushan@xxmu.edu.cn