Awake video laryngoscopy aided intubation as an alternative to awake fiberoptic intubation in a patient with difficult airway.

Abstract

Dear Editor, We are reporting the airway management of a 75-year-old male patient diagnosed with recurrent basal cell carcinoma (BCC) nose who had undergone multiple resections and facial reconstructive surgeries. He was posted for excision of recurrent BCC. On examination, his mouth had a fish-mouth appearance with restricted opening of approximately 4 cm. He had no nose, was edentulous with restricted tongue protrusion, and had a Mallampati score of 4. The patient had no other comorbidities and the investigations were within normal limits. After 6 h of fasting, the patient was taken up for surgery. The anesthetic plan was awake intubation followed by induction of general anesthesia (GA) and controlled ventilation. Fiberoptic bronchoscope (FOB) was unavailable and mask ventilation was seemingly impossible due to deformed facial contours. So, we planned to perform an initial awake check laryngoscopy under topical anesthesia. Following intravenous glycopyrrolate 0.2 mg, topicalization of oral cavity was done with 10% lignocaine spray. Then awake check laryngoscopy was performed with C MAC videolaryngoscope using D blade and we were able to visualize the glottic opening. Transtracheal block was given with 4 mL of 4% lignocaine, and then, under videolaryngoscopic visualization, a soft gum elastic bougie was introduced into the trachea. A 7.0mm internal diameter flexometallic endotracheal tube (ETT) was then railroaded over the bougie [Figure 1]. After observing regular end-tidal carbon dioxide waveforms, the patient was induced with propofol, paralyzed with vecuronium, and ETT was fixed at 21 cm at the left angle of the mouth. Fentanyl was used as an analgesic and anesthesia was maintained with isoflurane in an air–oxygen mixture. The intraoperative period was uneventful and the patient was extubated when fully awake after reversing neuromuscular blockade.Figure 1: Patient after intubationThough awake fiberoptic intubation (AFOI) is considered the gold standard for securing the airway in difficult airway patients, it may not be available always. Awake check laryngoscopy is helpful to plan mode of induction and intubation in difficult airway patients. Induction of GA in such patients is considered safe only if glottis could be visualized during check laryngoscopy. If FOB was available, oral AFOI would have been the ideal technique for our patient. Securing airway in patients with anticipated difficult airway in the absence of FOB could be accomplished by use of intubating laryngeal mask airway[1]or I gel,[2,3]a few among the many techniques described. We preferred intubation over supraglottic airway devices as they are bulkier than ETT and in the presence of reduced mouth opening, it would have further limited the surgical access for excision of the tumor at the mouth. Recent research has shown that videolaryngoscopes provide similar success rates and faster intubation times when compared with FOB-aided intubations in awake patients having difficult airways.[4,5]Optimal topicalization of the oral cavity, oropharynx, and the structures near the glottis as well as proper counseling of the patient are important for a successful outcome of this technique. We conclude that awake videolaryngoscopy followed by the introduction of soft gum elastic bougie into the trachea and railroading ETT over it is a safe alternative to AFOI during unavailability of FOB, provided the patient has adequate mouth opening. 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 Nil. Conflicts of interest There are no conflicts of interest.