Laryngeal mask airway facilitates awake fiberoptic intubation in a patient with severe oropharyngeal bleeding.

Abstract

Management of a compromised airway in a patient with maxillofacial trauma is often hindered by severe hemorrhage [1-3]. We report the airway management of a patient who had sustained blunt injury to the face with subsequent massive oropharyngeal bleeding and a suspected cervical spine injury. After awake fiberoptic endotracheal intubation orally failed twice because the severe hemorrhaging hindered the view through the fiberoptic intubating bronchoscope (FOB), awake fiberoptic endotracheal intubation was achieved by using the laryngeal mask airway (LMA) before it was necessary to implement the planned immediate awake tracheotomy. Case Report An 86-yr-old woman, height 165 cm, weight 50 kg, sustained blunt injury to the face, including bilateral fractures of the upper and lower jaws and a blunt fracture of the nasal bone. The patient was conscious but dyspneic, swallowing and spitting blood; pulse oximetry with the patient breathing room air was recorded at 76%, increasing to 88%-92% with the patient spontaneously breathing 100% O2. Visible injuries consisted of gross swelling on the anterior and lateral surfaces of the jaws, mouth, and nose. There was active bleeding from her nose and mouth. She was agitated and in acute respiratory distress. The patient was assumed to have a full stomach, almost certainly containing significant amounts of blood. The cervical spine was immobilized in a semirigid collar. In view of the respiratory distress and the severe hemorrhaging from the mouth, securing the airway was regarded as the urgent priority before radiographs or computed tomography scans. Because there was considerable risk of losing the airway under general anesthesia, the decision was made to attempt awake fiberoptic oral intubation with manual axial in-line stabilization of the head and neck. Consultants from trauma surgery were present; local anesthesia was performed pretracheally for immediate awake tracheotomy should the airway be lost. The equipment included a gum elastic bougie, a size 3 LMA, a percutaneous tracheotomy kit, several different preformed and oversized endotracheal tubes (ETTs), and a FOB. Two attempts to visualize the laryngeal inlet with the FOB proved impossible because copious amounts of blood in the oropharynx obscured the FOB's tip. Further attempts were abandoned when the pulse oximeter indicated that the patient was becoming hypoxemic (SaO2 80%-84%). After subsequent consultation with the trauma surgeons, the decision was made to immediately perform an awake tracheotomy. To maintain gas exchange during awake tracheotomy, a size 3 LMA was inserted into the pharynx. Insertion was accomplished with little difficulty without topical anesthesia in the emergency setting. Subsequent cuff inflation produced a clear airway with no patient discomfort. Spontaneously breathing 100% oxygen, the patient recovered from respiratory distress, and her peripheral oxygen saturation was immediately restored to 95%-97%. Although the patient was still bleeding excessively from the mouth and nose, subsequent fiberoptic inspection of the laryngeal inlet through the LMA showed a clear and surprisingly good view of the vocal cords. Considering the massive hemorrhage, there was a negligible amount of blood inside the LMA's breathing tube. Based on the restored gas exchange and the unobstructed view through the FOB, we quickly decided to make a single attempt at fiberoptic-guided intubation via the LMA. Had the attempt failed, we would have immediately continued with the original plan of creating a surgical airway. The fiberoptic-guided intubation via the size 3 LMA was performed as described by Benumof [1]. Passing the FOB through the vocal cords was successful at the first attempt. The subsequent railroading of the ETT over the FOB was uneventful. A postoperative interview revealed that the patient did not recall events during either awake fiberoptic intubation or the subsequent induction of anesthesia. Discussion Since its introduction into clinical practice, the LMA has proved to be a reliable and safe means of maintaining the upper airway. Ease of insertion and proven value when the airway is difficult suggest that the device may be useful for emergency airway management. Thus, LMAs are included in the ASA difficult airway algorithm [1] and other protocols of failed intubation scenarios. Nevertheless, a LMA is contraindicated in patients with a full stomach unless the airway has been lost [1]. Although a LMA does not protect the airway from aspiration of gastric contents, the LMA's cuff can protect the airway from secretions originating above the cuff [4]. The use of a LMA for tracheal intubation in patients considered to be at increased risk of aspiration of gastric contents has been reported by Asai [5]. The acutely injured patient requiring emergency surgery presents a unique and challenging set of circumstances. In our case, we were faced with a patient with a compromised airway, severe maxillofacial trauma, a suspected cervical spine injury, and, almost certainly, a full stomach. Securing the patient's airway was urgently required to maintain airway patency and gas exchange to allow further radiographic assessment and surgical procedures. The management of her airway was expected to be difficult because of the combination of maxillofacial trauma and severe oropharyngeal bleeding. Therefore, the endotracheal airway needed to be guaranteed while the patient was awake [3]. The options considered included 1) awake intubation with direct laryngoscopy using a standard laryngoscope, 2) awake intubation by mouth using a FOB, and 3) awake tracheotomy under local anesthesia, all with manual axial in-line stabilization of the head and neck. Two potential hazards are related to massive oropharyngeal bleeding: first, compromise of the airway with the risk of laryngeal soiling and aspiration of blood; second, interference with visualization of the laryngeal inlet and the vocal cords during endotracheal intubation. The first option failed, as a direct view into the laryngeal inlet proved impossible in our patient because of the severe bleeding from the oropharynx. The second option failed twice in our patient because of the massive hemorrhage. Consequently, in such a situation, insertion of a LMA may be a reasonable maneuver to quickly restore impaired gas exchange [1] while performing an awake tracheotomy under local anesthesia, mentioned above as the third option. Awake insertion of a LMA is a relatively moderate stimulus that results in little hemodynamic change [6]. The relative lack of stimulation in passing a LMA reduces the preparation, e.g., topical anesthesia or sedation, that an awake patient requires [1]. It should be noted that in cases of oropharyngeal pathology, e.g., tissue disruption, the LMA could create a false passage because it is inserted blindly. However, the LMA has been successfully used in the pre-hospital care of injured patients even with severe blunt facial trauma [2] and has been recommended as a useful adjunct to airway management before crico-thyroidotomy with cervical spine immobilization [7]. The main objection to the use of the LMA in the emergency situation is that it does not protect the airway from aspiration of stomach contents or from hemorrhage from the oropharynx. However, John et al. [4] have demonstrated that the LMA does have a limited ability to prevent dye introduced into the oropharynx from entering the larynx. The application of cricoid pressure to prevent aspiration of stomach contents is controversial [1]. The LMA was intended to be used in our patient only to protect the airway from soiling and to maintain gas exchange until the immediate awake tracheotomy could be performed under local anesthesia. However, the use of the LMA made awake fiberoptic endotracheal intubation possible and rendered awake tracheotomy unnecessary. The image through the FOB inside the LMA's breathing tube showed a clear and surprisingly good view of the vocal cords without the tip of the scope becoming obscured by a coating of blood, despite the large amounts of blood that had collected in the oropharynx. The main observations in our case report are that a LMA seems to have more than a limited ability to protect the larynx and trachea from blood that collects in the pharynx, in our case from excessive hemorrhaging. In addition, the view through the FOB is clear during subsequent awake fiberoptic intubation via the LMA because the FOB's tip is protected inside the LMA's breathing tube. If awake fiberoptic intubation fails because the FOB's tip is obscured with blood from the oropharynx, insertion of an LMA before a planned immediate awake tracheotomy may facilitate a subsequent fiberoptic endotracheal intubation. The LMA not only leads the tip of the FOB to the laryngeal inlet, but also protects the fibers on the FOB's tip from being obscured by blood or mucous. Because of the protection offered by the LMA, the clear image through the FOB may facilitate and accelerate endotracheal intubation.