ANESTHETIC MANAGEMENT IN

PATIENT WITH DIFFICULT AIRWAY

Case Report by

Ruby Anne D. Batobalonos, MD

Department of Anesthesia

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 Abstract

Airway management difficulties continue to be problem to the

anesthesiologist as it is the major cause for anaesthesia related morbidity and

mortality. Difficult airway includes difficult intubation (DI), difficult mask ventilation

(DMV) or both. Most of the anaesthesiologists give most attention on predicting

difficult intubation and difficult mask ventilation. Unpredicted difficult mask

ventilation can be life threatening to a patient with difficult intubation as it may result

into can’t ventilate – can’t intubate scenario. To secure the airway in predicted

difficult mask ventilation with difficult intubation, use of surgical airway can be

minimized by implementing the skillful use of alternative airway device – the

fiberoptic technique.

Introduction

During routine anaesthesia the incidence of difficult tracheal intubation has

been estimated at 3-18%. Difficulties in intubation have been associated with

serious complications, particularly when failed intubation has occurred.

Occasionally in a patient with a difficult airway, the anaesthetist is faced with the

situation where mask ventilation proves difficult or impossible. This is one of the

most critical emergencies that may be faced in the practice of anaesthesia. If the

anaesthetist can predict which patients are likely to prove difficult to intubate, he

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may reduce the risks of anaesthesia considerably.

Presented herein is the case of a 47-year-old, male, complained of

intermittent right upper quadrant pain for 3 months. Patient tolerated condition and

no medication taken. 2 months prior to condition, patient’s condition persisted with

associated pain after a fatty meal and described as gnawing at the right upper

quadrant and radiating to the back. Patient took mefenamic acid 500 mg tablet

orally which afforded minimal relief. Patient then sought consult at a private

hospital at Cagayan de Oro. Laboratories and imaging studies were taken,

ultrasound revealed multiple gallbladder stones. Patient was then scheduled for

an elective laparoscopic cholysectomy possible open a week after. Patient was

then preoperatively prepared a day prior to the surgery. At the operating room,

patient was inducted and prepared for intubation. Patient was then attempted to

be intubated however after several attempts patient was unsuccessfully intubated.

Procedure was then cancelled and rescheduled 3 days after. On the second

scheduled operation, patient was planned to be intubated under C-MAC, however,

still, patient wasn’t successfully intubated and was advised transfer to Chong Hua

Hospital for further management. Patient was admitted to Chong Hua Hospital for

a scheduled laparoscopic cholycystectomy under general anesthesia with Fiber

optic bronchoscope guided intubation. Patient had a successful surgery, improved

and eventually discharged.

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 Case

A 47 year old, male, maried, Roman Catholic, from Pueblo, Carmen

Cagayan De Oro, Misamis Oriental, was admitted for the first time in this institution

for scheduled laparoscopic cholecystectomy.

He is non- hypertensive, non-diabetic, non-asthmatic, non-smoker,

occasional alcoholic beverage drinker and no history of illicit drug use. No

maintenance medication, no history of allergies to food and drug and no previous

surgical procedure. no known medical conditions nor any history of seizure.

Patient had no previous surgery.

Family history includes diabetes mellitus and hypertension on maternal

side. Other family members were reportedly healthy.

History of present illness

3 months prior to admission, patient noted intermittent right upper quadrant

pain and radiating to the back, pain score of 4-6/10. Patient tolerated condition and

no medication taken.

2 months prior to condition, patient’s condition persisted with associated

pain after a fatty meal and described as intermittent gnawing pain at the right

upper quadrant and radiating to the back with pain score of 6-8/10. Patient took

mefenamic acid 500 mg tablet orally which afforded minimal relief. Patient then

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sought consult at a private hospital at Cagayan de Oro. Laboratories and imaging

studies were taken, ultrasound revealed multiple gallbladder stones.

Patient was then scheduled for an elective laparoscopic cholysectomy

possible open a week after. Patient was preoperatively prepared a day prior to the

surgery. At the operating room, patient was inducted and prepared for intubation.

After paralysis he was then attempted to be intubated however after several

attempts patient was unsuccessfully intubated. Procedure was cancelled and

rescheduled 3 days after. On the second scheduled operation, patient was planned

to be intubated under C-MAC, however, still, patient wasn’t successfully intubated

and was advised transfer to Chong Hua Hospital for further management.

Skin: warm, good skin turgor

HEENT: anicteric sclera, pink palpebral conjunctivae

Neck: supple, no masses, trachea midline

C/L: equal chest expansion, clear breath sounds, no rales

CVS: adynamic precordium, distinct heart sounds, no murmur

Abdomen: soft, flabby, normoactive bowel sounds, non tender

GUT: (-) KPS

Extremity: strong peripheral pulses, CRT <2 sec

CNS: within normal limits

On Airway examination: No deformities or abnormalities of the oral cavity, Mouth

opening: >3cm, Thyromental distance: >6cm, Mallampati: 4, Full neck extension,

No loose teeth or dentures

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 Course in the ward

Patient was examined awake, comfortable, not in distress, Pain score 0/10,

and was accompanied by his father. Vital signs were stable. Her weight is 16kg,

height of 154cm – all parameters were appropriate for her age. No headache, no

reports of hip/back pain. Her skin was warm with good mobility and turgor. No

limitation of movement on all extremities. Motor responses is 5/5 bilaterally, both

upper and lower extremities with no sensory deficit. The rest of her physical

findings were unremarkable.

Patient was admitted in a suite room. He was placed on regular diet.

Admitting laboratory exams: CBC, serum creatinine, serum sodium and

potassium, Prothrombine time, bleeding time, and urinalysis, chest x-ray were all

within normal limits. ECG was taken and showed sinus bradycardia with

intraventricular conduction delay. Consider brugada pattern. Omeprazole (Zefxon)

40 mg IVTT once daily, Cefoxitin (Monowel) 1 gram IVTT every 8 hours were given.

Acetate Ringer’s solution 1L at 60 cc/hr was started. Surgical management for

laparoscopic cholecystectomy possible open was discussed to the patient and her

family.

Considering the difficult mask ventilation and difficult tracheal intubation,

awake fiberoptic technique was planned to secure airway for giving general

anaesthesia. Procedure of the technique was explained to the patient and his

relatives and high risk consent for anaesthesia and surgery was obtained from

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them. Patient was starved for night before surgery. On the day of surgery, difficult

airway trolley and standby arrangement for emergency tracheostomy was kept

ready. Monitors like pulse oximeter, NIBP, ECG, ETCO2 were applied. An

intravenous line was secured with 18G venflon. Patient was premedicated with

midazolam (1mg) and fentanyl (25μg). To anaesthetize pharyngeal mucosa 2%

lidocaine spray was given to eliminate tracheobroncheal reflexes. Oxygen

supplementation was provided through nasal catheter (2 L/min) via right nostril.

Left nasal passage was lubricated with lubricant jelly and fiberoptic bronchoscope

passed through it. After manipulation, glottis visualized and larynx was sprayed by

injecting 1ml of 4% lidocaine through the injection port of bronchoscope. Awake,

nasal fiberoptic endotracheal intubation was done successfully, by guiding cuffed

endotracheal tube no. 7.5 over fiberoptic bronchoscope. Patient was induced with

propofol (100mg) and anaesthesia was maintained on oxygen, sevoflurane and

rocuromium. Intraoperative period was uneventful. Surgery lasted for two hour and

15 minutes. At the end of surgery neuromuscular blockade was reversed with

suggamadex (2.0mg). patient was then extubated and transported to PACU for

continuous monitoring. 2 hours after, patient was sent back to his room stable and

no subjective complaints.

Discussion

ASA Task Force on Management of the Difficult Airway defined Difficult Airway as

the clinical situation in which a conventionally trained anaesthesiologist

experiences difficulty with face mask ventilation of the upper airway, difficulty with

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tracheal intubation, or both. Practice guidelines for difficult airway also provided

descriptions for difficult mask ventilation and difficult intubation. Difficult airway

assessment needs comprehensive history, physical examination and specific tests.

In general adult population, incidence of difficult mask ventilation is 5%. Old age,

obesity, presence of beard, lack of teeth, history of snoring, Mallampati

classification III and IV, thyomental diastance <6cm, severely limited jaw protrusion

test are different predictors of difficult mask ventilation. Neck radiation is an

important predictor of impossible mask ventilation. Grading scale for mask

ventilation describes 4 grades (grades 1 – 4) with or without use of oral airway,

adjuvant, muscle relaxant or requiring two providers. Grade 3 and grade 4 are

DMV and IMV respectively. IMV and DMV combined with DI are two rare yet

clinical worrisome situations.

To manage difficult airway, ASA algorithm is widely accepted as a model

for the approach. Entry into the algorithm begins with the evaluation of the airway.

Although there is some debate as to the value of particular evaluation methods

and indices, the clinician must use all available data and his or her own clinical

experience to reach a general impression as to the difficulty of the patient’s airway

in terms of laryngoscopy and intubation, supraglottic ventilation techniques,

aspiration risk, or apnea tolerance. The evaluation should direct the clinician to

enter the ASA–DAA at one of its two root points: Awake intubation or intubation

attempts after the induction of general anesthesia. The decision to enter the

algorithm via either approach is a preoperative one.

A decision tree approach to enter the algorithm is required to do such

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preoperative choice. One must consider if an airway control is required. If it is not,

then regional or infiltrative is considered. Next, if airway control is being required

and direct laryngoscopy has been deemed difficult, supraglottic ventilation cannot

be used, aspiration is at risk and patient cannot tolerate an apneic periods, awake

intubation should be done otherwise, if the patient doesn’t have the

aforementioned factors, intubation after induction of anesthesia is being

considered.

Awake airway management is chosen when difficulty is anticipated that will

place the patient at jeopardy. For failed non-invasive airway intubation approach,

invasive airway access is considered. Awake intubation remains a mainstay of the

ASA’s difficult airway algorithm. The awake state provides maintenance of

spontaneous ventilation in the event that the airway cannot be secured rapidly,

increased size and patency of the pharynx, relative forward placement of the base

of the tongue, posterior placement of the larynx, and a cooperative patient. The

effect of sedatives and general anesthetics on airway patency may be secondary

to direct effects on motoneurons and on the reticular activating system. The sleep

apnea patient may be particularly prone to obstruction with minimal sedation. In

addition, the awake state confers some maintenance of upper and lower

esophageal sphincter tone, thus reducing the risk of relux. In the event that reflux

occurs, the patient can close the glottis and/or expel aspirated foreign bodies by

cough to the extent that these reflexes have not been obtunded by local

anesthesia. Lastly, patients at risk for neurologic sequelae may undergo active

sensory–motor testing immediately after tracheal intubation. In an emergent

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situation, there may be cautions but no absolute contraindications to awake

intubation. Local anesthetics are a cornerstone of awake airway control

techniques. The airway, from the base of the tongue to the bronchi, comprises an

undeniably sensitive series of structures. Lidocaine, an amide local anesthetic, is

available in a wide variety of preparations and doses. Topically applied, peak onset

is within 15 minutes.

Contraindications to elective awake intubation include patient refusal or

inability to cooperate (e.g., child, profound mental retardation, dementia,

intoxication) or allergy to local anesthetics. Most adult patients will appreciate an

explanation of the need for an awake airway examination and will be more

cooperative once they realize the importance of, and rationale for, any

uncomfortable procedures.

Intubation after induction of general anesthesia is for the situation in which

there may be anticipated difficulty with either ventilation or tracheal intubation, but

an uncorrectable situation is not expected. Unsuccessful initial intubation attempts

on difficult airway patients should prompt the clinician to: i.) call for help ii.)

returning to spontaneous ventilation and iii.) awakening the patient.

The fiberoptic bronchoscope is a ubiquitous instrument in anesthesia, being

available to 99% of surveyed active ASA members. It is now generally accepted

that for a variety of clinical situations, the fiberoptic bronchoscope is a critical tool

in the armamentarium of the anesthesiologist dealing with the awake or

unconscious patient who is, or appears to be, difficult to intubate. The fiberoptic

bronchoscope has proven to be the most versatile tool available in this regard.

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Unlike the other devices used to intubate the trachea, the fiberoptic bronchoscope

can also serve to visualize structures below the level of the vocal folds.

Contraindications to fiberoptic bronchoscopy includes: hypoxia, heavy airway

secretions not relieved with suction or Antisialagogues, bleeding from the upper or

lower airway not relieved with suction, local anesthetic allergy (for awake attempts)

and inability to cooperate (for awake attempts). Because the optical elements are

small (the objective lens is typically 2 mm in diameter or smaller), minute amounts

of airway secretions, blood, or traumatic debris can hinder visualization. Care must

be taken to remove these obstacles from the airway beforehand; application of

intramuscular or intravenous antisialagogues (e.g., glycopyrrolate, 0.2 to 0.4 mg;

atropine, 0.5 to 1 mg) will produce a drying effect within 15 minutes, but caution

should be taken in patients who may not be able to tolerate anincrease in heart

rate. Vasoconstriction of the nose using topical oxymetazoline, phenylephrine, or

cocaine reduces the chances of bleeding if this route is chosen. If an awake

intubation is planned using the iberoptic bronchoscope, the patient must be able

to cooperate—a “quiet” airway, with little motion of the head, neck, tongue, and

larynx, is vital to success. Finally, because fiberoptic bronchoscope-aided

intubation of the trachea can require significant time, especially if the clinician is

not facile with the device, hypoxia or impending airway loss is a contraindication,

and a more rapid method of securing an airway (e.g., LMA or surgical airway)

should be considered.

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 Conclusion

In conclusion, highest risk of hypoxia related morbidity and mortality lies in patients

who are predicted to have both DMV and DI. Whenever DMV with DI is anticipated,

for endotracheal intubation awake fiberoptic technique should be used as first line

technique and not as a backup or reserve technique to be used only after

conventional ways have failed.

Bibliography

1. Cormack RS, Lehane J. Difficult intubation in obstetrics.

Anaesthesia 1984;39:1105-11
2. Samsoon GLT, Young JRB. Difficult tracheal intubation:
a retrospective study. Anaesthesia 1987;42:487-90
3. Patil VU, Stehling LC, Zaunder HL. Fiberoptic Endoscopy
in Anesthesia. Chicago: Year Book Medical Publishers,
1983
4. Frerk CM. Predicting difficult intubation. Anaesthesia
1991;46:1005-8
5. Savva D. Prediction of difficult tracheal intubation. British
Journal of Anaesthesia 1994;73:149-53
6. Calder I, Calder J, Crockard HA. Difficult direct
laryngoscopy in patients with cervical spine disease.
Anaesthesia 1995;50:756-63
7. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P.
Predicting difficult intubation. British Journal of Anaesthesia
1988;61:211-6
8. Waters DJ Guided blind endotracheal intubation for
patients with deformities of the upper airway. Anaesthesia
1963;18:158-62
9. Barriot P, Riou B. Retrograde technique for tracheal
intubation in trauma patients. Critical Care Medicine.
1988;16:712-3
10. Shanther TR. Retrograde intubation using the subcricoid
region. British Journal of Anaesthesia. 1992;68:109-12
11. McCoy EP, Mirakhur RK. The levering laryngoscope.

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Anaesthesia 1993;48:516-9
12. Robelen GT, Shulman MS. Use of the lighted stylet for
difficult intubations in adult patients (abstract).
Anesthesiology 1989;71:A439
13. Frass M, Frenzer R. Zahler J, Lilas W, Leithner C.
Ventilation via the esophageal tracheal combitube in a case of

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