© Acta Anæsthesiologica Belgica, 2015, 66, n° 3

Abstract : Introduction : Expertise in airway manage­ment is a fundamental aspect of anesthesia practice. Fortunately ‘can’t intubate, can’t ventilate’ scenarios are extremely rare. In particular, patients with tumors on the right side of the oropharynx and larynx can be very problematic to intubate.Methods : We present an alternative intubation techni­que, whereby a C­MAC D­blade videolaryngoscope is loaded with a Frova catheter in the narrow, curving chan­nel within the blade’s infero­posterior aspect on the left side of the blade. This technique can be a successful ­alternative­in­patients­with­difficult­airways.Results : The proposed technique was successfully demonstrated in a case whereby a 47­year old male with premetrics­ of­ a­ difficult­ airway,­ presented­with­ a­ large­mass in the right supraglottis and hypopharynx with through-and-through­ thyroid­ cartilage­ infiltration,­ obstructing completely the view of the glottis with direct laryngoscopy. The referral hospital considered the pa­tient unintubatable and sent the patient to our academic center for treatment. Endotracheal intubation with the new­technique­was­successful­at­the­first­attempt.Conclusions : The C­MAC D­Blade videolaryngoscope­bougie technique provides an alternative method to intu­bate­patients­with­difficult­airways,­even­in­exceptional­situations such as in patients with a large right­sided oropharynx­larynx tumor.

Key words : Larynx tumor ; failed intubation ; CICO ; videolaryngoscopy ; frova catheter.

IntroductIon

Endotracheal intubation can be challenging in patients­ with­ difficult­ airways.­ According­ to­ the­NAP4­study, a ‘can’t intubate, can’t ventilate’ sce­nario occurs in fewer than 1 in 5,000 routine general anesthesia procedures, but accounts for up to 25% of all anesthesia­related deaths (1­4).

Videolaryngoscopy offers advantages over classic laryngoscopy, especially in patients with dif­ficult­airways­(5-7).­We­suggest­an­alternative­intu­bation method to those currently available by utilis­ing the C­MAC®­D­blade (8) videolaryngoscope

(Karl Storz, Tuttlingen, Germany) and a bougie/ introducer with a ‘railroad’ technique.

case report

A 47­yr­old indigenous male (height : 160 cm ; weight : 54 kg ; BMI : 21 kg/m2 ; ASA 4, Mallam­pati grade IV, mouth opening 2 cm, thyromental distance 5.2 cm) presented with a 2 week history of dysphagia and hemoptysis. He was a long­term chronic alcohol abuser and smoker, and reported re­cent 5­10 kg of weight loss and hypertension. Chest X­ray showed the appearance of a right­sided laryn­geal tumor with an abnormal lymph node, deemed likely­to­be­malignant.­CT­scan­confirmed­a­laryn­geal primary tumor eroding into the thyroid carti­lage staged at T4aN2M0, obliterating completely the right side of the glottis entrance. PET scan dem­onstrated a mass in the right supraglottis and hypo­pharynx with through­and­through thyroid cartilage infiltration­and­bilateral­nodal­metastases.­Inciden­tally, the right palate also appeared ‘hot’ on PET scan. Flexible nasal endoscopy showed a large supraglottic lesion on the right false cord extending

(Acta Anaesth. Belg., 2015, 66, 87-90)

André A. J. Van Zundert, Professor of Anaesthesiology, M.D., Ph.D., F.R.C.A., E.D.R.A., F.A.N.Z.C.A ; Stephen P. Gatt, Associate Professor of Anaesthesiology, M.D., F.A.N.Z.C.A., F.R.C.A., F.C.I.C.M.

(*) Department of Anaesthesiology and Perioperative Medi­cine, The University of Queensland School of Medicine & Royal Brisbane & Women’s Hospital, Brisbane, Qld, Australia.

(**) Department of Anaesthesia, Wales Anaesthesia, Prince of Wales Hospital and the University of New South Wales, Randwick, NSW, Australia.

Corresponding address : Prof. André Van Zundert, Professor & Chair Discipline of Anesthesiology, The University of Queensland, Faculty of Medicine & Biomedical Sciences, Royal Brisbane & Women’s Hospital, Ned Hanlon Building – level 4, Department of Anaesthesia & Perioperative Medi­cine,­ Butterfield­ St,­ Herston-Brisbane,­ Queensland­ 4029,­Australia. Tel. : +61 7 3646 5673. Fax : + 61 7 3646 1308. E­mail : vanzundertandre@gmail.com and

gattsp@gmail.com

A novel method of intubation and orogastric tube insertion using a C­MAC­D­blade videolaryngoscope­bougie technique

a. a. J. Van Zundert (*) and s. p. Gatt (**)

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blade’s infero­posterior aspect on the left side of the blade (Fig. 1C­1D) which can accommodate a 70cm­long 14Fr Single Use Frova Airway Intubat­ing Introducer/oral endotracheal tube changer (CookTM Bjaeverskov, Denmark) or, alternatively, a 70­cm­ 15­Fr­ Teflon­ Single­ Use­ Exchange­ Guide­Bougie with Coudé Tip (Smiths Medical Int., Hythe, Kent, UK), provided both the channel and introduc­er are well lubricated before use. This technique has proven to be most satisfactory and is an additional, easy-to-implement­ strategy­ when­ difficult­ airway­intubation is anticipated and when right­sided oral tumors obliterate the view or access to the glottis entrance.

In order to insure successful endotracheal tube placement into the airway using this technique, the following steps are necessary : 1) lubrication of the Frova Introducer or bougie (catheter) and internal surface of the D­Blade channel ; 2) loading of the lubricated intubating catheter into position onto the D­blade (Fig. 1C­1D) with the catheter tip protrud­ing no further than the D­blade distal end ; 3) hold­ing the videolaryngoscope in either the left or right hand, carefull progression of the D­blade with bou­gie/intubating catheter/exchange catheter assembly into the mouth under direct vision ; 4) obtaining a view on the C­MAC screen in the standard recom­mended fashion ; 5) positioning of the tip of the D­blade into the vallecula under guidance using the image on the C­MAC monitor screen (Fig. 1E) ; 6) pointing the tip of the Frova intubating introduc­er/bougie to face the middle of the glottic entrance (which will usually now be visible in the center of the monitor screen) ; 7) using the free hand to ad­vance the tip of the bougie/intubating catheter and inserting it about 7 cm over the vocal cords into the trachea (Fig. 1E) ; 8) removing the D­blade and un­clip the catheter from the channel whilst holding firmly­onto­the­bougie/intubating­catheter­just­out­side the lips to retain the catheter’s intratracheal ­position­;­9)­loading­by­a­trained­assistant­now­the­endotracheal tube onto the proximal end of the bougie/intubating catheter/exchange catheter ; and 10) using the latter to railroad the endotracheal tube into the trachea (Fig. 1F). While this last step can be undertaken ‘blind’ as in the standard blind railroad technique, it can be conducted under continuous visual guidance if the D­blade (Fig. 1G) is re­insert­ed into the mouth.

According to the anesthesiologist preference, the videolaryngoscope can be held in the left or the right hand, while the free hand can be used to ad­vance the bougie (catheter). This avoids the need to “cross” hands. Experience has shown us that, in

to the aryepiglottic fold. The right anterior glottis could not be viewed because of the tumor. At the time of presentation, the patient had acute airway obstruction at the level of the larynx, presumably from his carcinoma.

The patient had been transferred to our hospi­tal (RBWH) for surgery because he was deemed ‘unintubatable’ and because of the magnitude of the surgery required. Because the patient could not be intubated, a tracheostomy had been performed un­der local anesthesia before transfer. Surgeons planned : a 1) pharyngo­laryngectomy and esopha­gectomy ; 2) esophageal replacement using a stom­ach­pull-up­;­3)­reanostomosis­(jejunal­flap­repair)­;­4) right 1­5 area neck dissection ; and 5) left 2­4 zone neck dissection. The tumor was known to be large, fragile to the point of crumbling when touched and bleeding when interfered with.

Because surgery included removal and exci­sion of the tracheostomy area an oral/nasal endotra­cheal tube (ETT) was needed and, in the operating theatre, both the ENT and maxillofacial surgeons chose the oral route even though MRI studies sug­gested that intubation would not be possible. We induced anesthesia using the intravenous route because we had the advantage of the tracheostomy. In this case, a blind retrograde technique through the existing tracheostomy would have been inap­propriate both in advancing the Seldinger wire or tube changer and the subsequent railroad technique because of the size and friability of the tumor.

We opted for the C­MAC­D­blade with Frova as­first­line­technique­because­we­regarded­our­tech­nique as the most likely to be successful. Though previously regarded as impossible, we eased the blade gingerly down the left side carefully avoiding the large tumor on the right side. The left cord was visible but the right cord was obliterated by the large invading laryngeal tumor (Fig. 1A). An en­larged epiglottis made the intubation more complex. Once the C­MAC­D­blade/Frova catheter technique identified­the­tracheostomy,­a­railroad­intubation­on­the­first­attempt­was­possible,­ straightforward­and­‘easy’. As anticipated, there was minor bleeding from the tumor (Fig. 1B). This ceased within a few seconds. Operation and recovery were uneventful. Patient gave written consent for publication.

dIscussIon

The C­MAC®­D­blade, designed by Professor dr. Volker Dörges (University of Kiel Germany) features a narrow, curving channel within the

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c-mac-d-blade videolaryngoscope-bougie technique 89

Fig. 1. — Picture taken with videolaryngoscopy of a patient with a large invading laryngeal tumor on the right, oblit-erating the anterior view of the glottis, before (Fig. 1A) and after (Fig. 1B) endotracheal intubation, with a nasogastric tube in position ; and the sequence of insertion using the C-MAC D-blade videolaryngoscope, mounted with an intu-bating catheter (Fig. 1C to 1G). Note the clear difference between the tracheal and esophageal orifices (Fig. 1H).

A

E

G

C

B

F

H

D

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adjunct manipulation techniques during a success­ful endotracheal tube insertion.

conclusIon

Our new intubation technique provides to the operator a simple sequence, with small investment in time, to achieve a rapid, satisfactory outcome even in those where attempts at intubation have proved unsuccessful. Furthermore, it provides an­other application of the C­MAC®­D­Blade. Unlike the situation with other videolaryngoscopes, both direct and indirect laryngoscopy can be performed and both a ‘channelled’ (using the unique, previ­ously unpublished, technique described in this pa­per) and ‘unchannelled’ method are possible.

References

1. Woodall N. M., Cook T. M., National census of airway management techniques used for anaesthesia in the UK : first phase of the 4th National Audit Project at the Royal College of Anaesthetists, br. J. anaesth., 106, 266­71, 2011.

2. Fourth National Audit Project of the Royal College of Anaesthetists­ and­ Difficult­ Airway­ Society,­ Major complications of airway management in the United Kingdom. Report and Findings,­ISBN­978-1-9000936-03-3.­Royal College of Anaesthetists, London, 2011.

3. Cook T. M., MacDougall­Davis S. R., Complications and failure of airway management, br. J. anaesth., 109 (S1), i68­i85b, 2012.

4. Cook T. M., Woodall N., Frerk C., Major complications of airway management in the United Kingdom. 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society Part 1 Anaesthesia, br. J. anaesth., 106, 617­31, 2011.

5. Van Zundert A. A. J., Maassen R. L. J. G., Hermans B., Lee R. A., Videolaryngoscopy – making intubation more successful, acta anaesthesIol. belG., 59, 177­17, 2008.

6. Maassen R., Lee R., van Zundert A., Cooper R., The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient. J. anesth., 23,­445-8,­2009.

7. van Zundert A., Pieters B., Hoogbergen M., Videolaryn-goscopy offers advantages over classic laryngoscopy in a patient with seriously limited lip opening, J. anesth., 26, 468-9,­2012.

8. Cavus E., Neumann T., Doerges V., Scharf E., Wagner K., Bein B., Serocki G., First clinical evaluation of the C-MAC D-blade videolaryngoscope during routine and difficult intubation, anesth. analG., 112, 382­5, 2011.

9.­ Greenland K. B., Bradley P., D-blade C-MAC videolaryn-goscopy™ with the Frova Intubating Introducer™, anaesth. IntensIVe care, 43,­268-9,­2015.

either case, crossing hands is not really a problem because the distal end of the laryngoscope handle and the catheter are in very close proximity.

If an orogastric tube also needs to be inserted, an identical technique can be used. This time the orogastric tube is loaded into the D­blade channel while the blade tip is adjusted to sit slightly more posteriorly to face the esophagus. With the tip of the blade in position, one can clearly distinguish the esophageal­ orifice­ from­ the­ glottic­ entrance­(Fig. 1H).

The narrow, curving channel can also be used to administer oxygen during the process of intuba­tion (if a Frova or Cook exchange catheter is used) or to suction the oropharynx and clear any blood or saliva (if a long Y suction catheter is used). The anesthesiologist should test, before use on patients, whether the oxygen delivery catheter or suction catheter­ (eg.­ Y-suction)­ fits­ snugly­ within­ the­ channel.

If the tip of the intubating catheter points too high onto the anterior commissure and, therefore, is anterosuperior to the vocal cords, this can prevent from being able to insert the endotracheal tube into the trachea. This can be solved by withdrawing the D­blade further by 1­2 cm and by gently rotating the bevel of the endotracheal tube counter­clock­wise during the railroad procedure.

If dislocation of the airway intubating catheter was to occur during a blind railroad procedure, the procedure would need to be repeated, this time ensuring that the catheter sits within the trachea whilst, at the same time, monitoring and correcting peripheral oxygenation. This was not necessary in any of our subjects.

This new technique is easy to learn and to teach to others. We have used this method in over fifty­patients­with­premetrics­suggesting­a­difficult­airway. All intubations using this technique were successful­on­the­first­attempt.­My­co-worker­Keith­Greenland also mentioned our new technique in a case­reported­in­the­Australian­literature­(9).

Further studies may be helpful to : 1) further validate our novel suggested method ; 2) compare our­ technique­ in­ difficult­ airways­ with­ a­ control­group in which the bougie is not used ; 3) demon­strate the optimal qualities and physical properties of the introducer ; and 4) validate the sequence and

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