Difficult intubation managed using standard laryngeal mask airway, flexible fibreoptic bronchoscope and wire guided enteral feeding tube

Successful wire-guided fiberoptic nasotracheal intubation in a patient with hemifacial microsomia - A case report

Background

Patients with hemifacial microsomia may have a difficult airway due to the accompanying mandibular deformity. Fiberoptic bronchoscope-guided intubation is commonly used method for difficult airway management. However, awake fiberoptic nasotracheal intubation has several disadvantages, including difficulty in advancement of the endotracheal tube (ETT) due to the resistance between the ETT and bronchoscope. Wire-guided fiberoptic nasotracheal intubation may help to overcome the drawbacks of the conventional method.

Case

An 18-year-old man with hemifacial microsomia was scheduled for double-jaw surgery. In preoperative evaluation, he had severe retrognathia and expected difficult airway. We successfully performed wire-guided fiberoptic nasotracheal intubation combined with high-flow nasal cannula and deep sedation without any complications.

Conclusions

A guidewire may be useful, in case of difficultly in advancing the ETT or if a smaller tube is required, while performing intubation with FOB in patients with difficult airways.

Wire-guided (Seldinger technique) intubation through a face mask in urgent, difficult and grossly distorted airways

We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

Wire-guided catheter exchange after failed direct laryngoscopy in critically ill adults

STUDY OBJECTIVE

To describe a technique for tracheal intubation after failed direct laryngoscopy using a Laryngeal Mask Airway (LMA) to secure the airway and to establish ventilation, and as a conduit for fiberoptic intubation utilizing a pre-packaged, convenient, and commercially available wire-guided catheter exchange kit.

DESIGN

Retrospective case series.

SETTING

University hospital.

MEASUREMENTS

The cases of 5 critically ill adult patients who required intubation for respiratory failure, and in whom direct laryngoscopy was unsuccessful and unanticipated, were reviewed. Difficult intubation was defined as > or = two attempts by direct laryngoscopy and use of an airway adjunct/alternate airway device, or > or = three attempts by direct laryngoscopy. Occurrence of hypotension, hypoxemia, and the time required to accomplish the intubation were recorded.

MAIN RESULTS

Patients' tracheas were intubated in the emergency department (n = 2), the intensive care unit (n = 2), and the radiology department (n = 1). An Eschmann endotracheal tube (ETT) introducer was used in 4 of the 5 patients, and a GlideScope was used in the fifth patient. After failed direct laryngoscopy, an LMA Classic was inserted to gain an airway, after which a fiberoptic bronchoscope and wire-guided catheter exchange set was used to change the LMA to a conventional ETT. Ventilation was maintained via the LMA with an attached bronchoscope adapter throughout the procedure.

CONCLUSIONS

In all 5 patients, the trachea was successfully intubated within three minutes on the first attempt, using a wire-guided exchange, without hypoxemia or hypotension.