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 Table of Contents  
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 93-94

Positioning for awake fiberoptic intubation: a unique challenge and a novel solution!

1 Department of Anaesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India
2 Department of Oncoanaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India

Date of Submission03-Sep-2015
Date of Acceptance09-Apr-2016
Date of Web Publication6-Sep-2016

Correspondence Address:
Shagun B Shah
House No 174 – 175, Ground Floor, Pocket-17, Sector-24, Rohini, Delhi 110 085
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2356-9115.189786

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How to cite this article:
Shah SB, Hariharan U, Chowdhury I, Bhargava AK, Pathak S, Choudhary M. Positioning for awake fiberoptic intubation: a unique challenge and a novel solution!. Res Opin Anesth Intensive Care 2016;3:93-4

How to cite this URL:
Shah SB, Hariharan U, Chowdhury I, Bhargava AK, Pathak S, Choudhary M. Positioning for awake fiberoptic intubation: a unique challenge and a novel solution!. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Jun 4];3:93-4. Available from: http://www.roaic.eg.net/text.asp?2016/3/2/93/189786

An anticipated difficult airway can turn out to be an anesthesiologist's nightmare, especially if preoperative preparation and positioning are problematic. We present a unique case of a difficult airway that posed problems in all six basic management aspects mentioned in the current American Society of Anesthesiologists difficult-airway algorithm [1] – namely, difficulty in ventilation, difficulty in performing laryngoscopy, difficulty in supraglottic airway placement, difficulty in intubation, difficulty with patient cooperation, and difficulty in performing tracheostomy. Our patient had severe radiotherapy-induced neck contracture [2] and moderate degree of kyphoscoliosis. Mild stridor and airway obstruction along with spine deformity made him unable to lie supine without arterial desaturation. An improvised operation theater (OT) table position was employed to facilitate bronchoscopic intubation. As per standard protocol, a difficult-airway cart was readied, and awake fiberoptic bronchoscopic (FOB) intubation was planned.

A 52-year-old ASA grade 1 male patient weighing 50 kg was posted for percutaneous endoscopic gastrostomy (PEG) insertion. PEG insertion attempted previously under local anesthesia was abandoned because of a dip in arterial oxygen saturation when the patient was placed in the supine position. He was a known case of carcinoma of the left buccal mucosa and had been treated with commando operation and segmental mandibulectomy followed by adjuvant radiotherapy and chemotherapy in 2005. He had undergone two surgeries for recurrence of malignancy, in 2006 and in 2014. He had erosion of the hard palate, right upper alveolus, and floor of right maxillary sinus for which he had undergone composite resection and external beam radiotherapy. His current preoperative hematological and biochemical investigations were within normal limits. His preoperative vital parameters were within the normal range.

The patient could not lie down supine because of stridor, airway obstruction, severe neck contracture, and spine deformity. He had no mouth opening, not even for insertion of a straw for sipping liquids, hence the requirement of PEG insertion. A surgical airway was not an option because of the distorted anatomy of the anterior aspect of the neck owing to fibrosis and strictures due to previous mandibulectomy, cervical lymph node dissection, pectoralis major myocutaneous flap reconstruction, tracheostomy scar, and several cycles of radiotherapy [2]. His spine was bent like a bow with concavity facing anteriorly. He was slightly more comfortable in the lateral position. His airway was nebulized with 5 ml 4% lignocaine and 10% lignocaine spray to prepare for awake FOB intubation [3],[4]. The table was lowered to the lowermost level. A double sandbag was placed beneath the shoulders and a ramp was created. The OT table was manipulated until it assumed the bow-like contour of the patient. The Trendelenburg button was pressed until the head end had become parallel to the floor of the OT and the foot end had risen, augmenting the venous return and cardiac output [Figure 1].
Figure 1 Improvised operation table positions.

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The anesthesiologist stood on an elevated platform to perform flexible FOB. FOB insertion of a 7-mm cuffed nasotracheal tube through the prepared left nostril was attempted. A nasal catheter was inserted through the right nostril for oxygen supplementation. The anatomy was highly distorted and the structures were unidentifiable because of edema and fibrosis. Linocaine spray of 4% was utilized (‘say-go’ technique) and the glottis negotiated successfully. The tube was fixed at the 27 cm mark after confirming bilateral air entry. Titrated slow intravenous fentanyl (total 100 μg) and propofol 50 ml were given, followed by muscle relaxant. Anesthesia was maintained with oxygen+air+sevoflurane mixture. PEG insertion was abandoned by the surgeons as the proximal esophagus could not be negotiated with the endoscope. Instead, a feeding jejunostomy was performed and the surgery proceeded uneventfully. After adequate reversal, the patient was not extubated in view of known difficult airway and was instead maintained on pressure support ventilation overnight in the oncosurgical intensive care unit. The endotracheal tube was removed over a tube exchanger device [5] the following day.

Awake nasal FOB intubation was the only option available in view of restricted mouth opening, severe neck contracture, kyphoscoliosis, and fibrotic airway structures. We had kept alternative difficult-airway equipment ready in the event of failed FOB. Videolaryngoscopy, retromolar intubation, submental intubation, and intubating laryngeal mask airway could not be used as there was no mouth opening and the retromolar space was not adequate in our patient. The only other options available were abandonment of the procedure, blind nasal intubation, retrograde intubation, and cricothyrotomy. Abandoning the procedure amounted to lifelong parenteral nutrition for the patient. Blind nasal intubation was discarded as nasal intubation under fiberoptic vision was a better alternative. Anticipating bleeding complicating nasotracheal intubation we had kept retrograde intubation [6] as a standby. Retrograde intubation and cricothyrotomy are more invasive than FOB and would have been unusually difficult to perform owing to the distorted anatomy described above. The key to success was to maintain the patient awake with intact positioning for FOB. The clinical factor that we want to emphasize in this patient is the unique position in which we performed the FOB. Optimal positioning is crucial for successful endotracheal intubation, especially in an airway compounded by all six basic management problems. Positioning issues for fiberoptic intubation must be addressed on a case to case basis. By altering the ergonomics of the OT table, we were able to achieve the desired position so that the head was parallel to the floor while maintaining patient comfort and oxygen saturation.

  Acknowledgements Top
Conflicts of interest

There are no conflicts of interest.

  References Top

Apfelbaum JL, Hamburg CA, Caplan RA. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology 2013; 118:251–270.  Back to cited text no. 1
Engelmier RL, King GE. Complications of head and neck radiation therapy and their management. J Prosthet Dent 1983; 49:514–522.  Back to cited text no. 2
Ramesh S. Fiberoptic airway management in adults and children. Indian J Anaesth 2005; 49:293–299.  Back to cited text no. 3
Fulling PD, Roberts JT. Fiberoptic intubation. Int Anesthesiol Clin 2000; 38:189–217.  Back to cited text no. 4
Duggan LV, Law JA, Murphy MF. Brief review: supplementing oxygen through an airway exchange catheter: efficacy, complications, and recommendations. Can J Anesth 2011; 58:560–568.  Back to cited text no. 5
Biswas BK, Bhattacharya P, Joshi S, Tuladhar UR, Baniwal S. Fluoroscope aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening. Br J Anaesth 2005; 94:128–131.  Back to cited text no. 6


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