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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 154-156

Innovative use of fibreoptic bronchoscope as a flexible, manoeuvrable stylet during C-MAC videolaryngoscopy


Department of Anaesthesiology, MS Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission09-Sep-2019
Date of Acceptance06-Oct-2019
Date of Web Publication30-Jan-2020

Correspondence Address:
Dr. Suresh Govindswamy
MS Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_28_19

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  Abstract 


The C-MAC videolaryngoscope has been used along with bougies, pliable metal stylet and optical stylet during the management of the difficult airway. The fibreoptic bronchoscope (FOB) was used as a last resort in our patient to direct the endotracheal tube into the trachea. A 74-year-old male (American Society of Anesthesiologists Physical Status III) who had undergone cervical spine instrumentation 12 years prior was scheduled for laparoscopic prostatectomy. On examination, he was found to have restricted neck movements. In view of the anticipated difficult airway, awake fibreoptic intubation was planned, for which the patient did not give consent. A FOB with a preloaded endotracheal tube was used as a flexible stylet. The fibrescope was manoeuvred towards the glottis which was visualised with the help of the C-MAC videolaryngoscope, resulting in successful intubation.

Keywords: C-MAC videolaryngosope, difficult airway, fibreoptic bronchoscope, flexible stylet


How to cite this article:
Govindswamy S, Shenoy B, Rajamohan S, Mitali P. Innovative use of fibreoptic bronchoscope as a flexible, manoeuvrable stylet during C-MAC videolaryngoscopy. Airway 2019;2:154-6

How to cite this URL:
Govindswamy S, Shenoy B, Rajamohan S, Mitali P. Innovative use of fibreoptic bronchoscope as a flexible, manoeuvrable stylet during C-MAC videolaryngoscopy. Airway [serial online] 2019 [cited 2020 Apr 10];2:154-6. Available from: http://www.arwy.org/text.asp?2019/2/3/154/277325




  Introduction Top


Successful management of a difficult airway is an important and crucial aspect of safe anaesthetic care. A difficult intubation is defined as more than three attempts to intubate in 10 min or whereby it is not possible to visualise any portion of the vocal cords with conventional laryngoscopy or intubation that requires more than one attempt, a change in blade, an adjunct to direct laryngoscopy or the use of alternative devices.[1] The C-MAC is a type of videolaryngoscope which alleviates the need for aligning the axes and provides better glottic exposure through its panoramic view.[2] However, the C-MAC does not always guarantee successful intubation, as there might still be difficulty in directing and guiding the endotracheal tube between the vocal cords.

We present a case of anticipated difficult airway in whom the airway was secured using the fibreoptic bronchoscope (FOB) as a flexible stylet while the glottis was visualised using the C-MAC videolaryngoscope.


  Case Report Top


A 74-year-old male diagnosed with prostatic cancer was scheduled for laparoscopic prostatectomy. He was also diagnosed as type II diabetes mellitus which was well controlled with oral hypoglycaemic agents. He had undergone cervical spine instrumentation (C4 to C7) 12 years prior.

On examination, the patient weighed 82 kg. He was haemodynamically stable, and systemic examination was essentially normal. Airway examination revealed restricted neck movements (limited to 15° flexion and 30° extension). Mouth opening was adequate with modified Mallampati Class III. In view of these airway findings, we anticipated a difficult airway. Blood investigations, electrocardiogram and ECHO were within the normal limits. After a detailed preanaesthetic evaluation, written informed consent was obtained, adequate blood was arranged and the patient was accepted under the American Society of Anesthesiologists Physical Status III. In view of the anticipated difficult airway, our plan was to perform an awake fibreoptic intubation. As the patient did not give consent, we opted to intubate using the C-MAC videolaryngoscope.

The patient was premedicated with intravenous (IV) pantoprazole 40 mg and IV ondansetron 8 mg. He was shifted to the operation theatre, and the baseline monitoring of electrocardiogram (Lead II), noninvasive blood pressure, pulse oximetry and temperature was established. The baseline parameters were recorded, and IV access was secured in the left forearm. The difficult airway cart was checked and kept ready.

The patient was preoxygenated with 100% oxygen for 3 min, and anaesthesia was induced with IV midazolam 1 mg, fentanyl 100 mcg and propofol 150 mg. After confirming bag-mask ventilation, atracurium 40 mg was given to produce muscle relaxation. After mask ventilation was done for 3 min, videolaryngoscopy was performed using the C-MAC (D-blade) with head in the neutral position. Despite satisfactory visualisation of the vocal cords, it was difficult to direct the tube towards the vocal cords and intubate the trachea. The tube was manoeuvred to negotiate it anteriorly towards the glottis, but it was unsuccessful. It was attempted to intubate with bougie which was also unsuccessful. The patient was mask ventilated with 100% oxygen in between the attempts. Oxygen saturation was maintained around 94%–95% with nasal prongs at 3 L/min. A FOB with a preloaded endotracheal tube was used as a flexible stylet, while the C-MAC videoscope was used to visualise the glottis. We did not use the optical system of the bronchoscope for glottic visualisation. The tip of the bronchoscope was visualised on the C-MAC videoscope and used as a flexible stylet, while the glottis was visualised using the C-MAC videolaryngoscope. The tip of the FOB could be manoeuvred using the control lever towards the glottis and the FOB passed through the vocal cords without any trauma to airway followed by railroading of the endotracheal tube. The position of the endotracheal tube was confirmed using auscultation for bilateral air entry and the appearance of a square wave on the capnograph.

At the end of the surgery, the residual neuromuscular blockade was antagonised, and the patient was extubated on the table once he was awake and met standard extubation criteria. The postoperative period was uneventful.


  Discussion Top


The C-MAC videolaryngoscope with its miniature video camera at the tip of the blade and steep blade angulation allows better glottic visualisation.[3] However, it is well known that better glottic visualisation does not always guarantee successful intubation. The steep angulation of C-MAC blade can make intubation difficult despite the use of a bougie or rigid stylet. The FOB has its own disadvantages such as a tunnelled narrow-angled view which can become obscured with secretions and blood. There might be difficulty in negotiating the scope around obstructing structures and through collapsed upper airway in anaesthetised patients.

Combining the C-MAC videolaryngoscope with the FOB could provide a novel approach to increase the probability of successful intubation in a situation such as the one faced by us. The C-MAC videolaryngoscope was used to create oropharyngeal space to navigate the FOB. The tip of the bronchoscope was manoeuvred into the airway while maintaining the view of the glottis with the C-MAC videolaryngoscope without the need for using the optical system of the FOB.[3]


  Conclusion Top


The use of a FOB as an intubation conduit or flexible stylet introduced under the guidance of a videolaryngoscope improves intubating conditions while decreasing the number of attempts for successful endotracheal intubation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma D, Kim LJ, Ghodke B. Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bronchoscope in a patient with Cowden syndrome. Anesthesiology 2010;113:253-5.  Back to cited text no. 1
    
2.
Maghawry K, Rayan AA. Tracheal intubation with the aid of fibreoptic bronchoscopy with or without C-MAC device in patients with a suspected difficult airway undergoing elective uvulopalatopharyngoplasty. Ains Shams J Anesthesiol 2015;8:308-15.  Back to cited text no. 2
    
3.
Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: An analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011;114:34-41.  Back to cited text no. 3
    




 

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Abstract
Introduction
Case Report
Discussion
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