Combined use of a videolaryngoscope and a flexible bronchoscope for awake tracheal intubation when front‐of‐neck airway is not an option

Summary

We report a case of successful tracheal intubation with the combined use of a videolaryngoscope and flexible bronchoscope in a patient with difficult airway when both techniques had individually failed. A 35‐year‐old man presented with airway obstruction due to massive neck swelling causing hypoxia, stridor and respiratory distress. He had a history of oral cancer which had been resected with bilateral neck dissection and free flap reconstruction 2 months previously. Due to extensive anterior neck swelling, we judged that front‐of‐neck airway would not be a suitable approach. After unsuccessful attempts at awake tracheal intubation with videolaryngoscopy and flexible bronchoscopy separately, we combined both techniques with a successful outcome. By using a combined technique to address the specific problems presented by this case, a life‐threatening emergency was resolved. This case highlights why it is useful for anaesthetists to be familiar with multiple techniques to awake tracheal intubation, both individually and in combination.

Introduction

One of the most challenging clinical situations encountered by anaesthetists is the management of difficult airway, especially when it is compounded by urgency and a threat to life [1]. Patients with oral cancers that have been treated with neck dissection and free flap followed by chemotherapy can re‐present with massive face and neck swelling [2]. This is thought to be due to secondary lymphoedema arising as a result of damage to the local lymphatic system during tumour resection [3]. Sometimes, this swelling can progress to the point where it creates serious functional problems such as airway obstruction. In such emergency situations, management of an already difficult airway becomes even more problematic due to a combination of urgency and human factors [4, 5, 6]. In this report, we present a successful emergency tracheal intubation with the combined use of a videolaryngoscope and a flexible bronchoscope in a patient with extensive face, neck and flap oedema, causing severe airway obstruction and respiratory distress. Front‐of‐neck airway (FONA), either in the form of tracheostomy or cricothyroidotomy, was not viable either as a primary approach or a backup plan due to the extent of the swelling. Awake tracheal intubation was therefore deemed to be the only safe option for this patient.

Report

A 35‐year‐old man (height 157 cm; weight 55 kg) with known of squamous cell carcinoma of the floor of the mouth, which had been treated with composite resection, bilateral radical neck dissection and antero‐lateral thigh free flap surgery, presented with difficulty in breathing 2 months following his surgery. The patient had low peripheral oxygen saturations (88% on presentation), and stridor was evident along with gross oedema of the eyelids, cheeks, lips and entire neck (Fig. 1). The free flap had markedly swollen, imposing significant pressure on the anterior neck structures. The patient was positioned propped‐up on pillows and was unable to lie down beyond 45° due to worsening of the airway obstruction. Supplemental oxygen delivered via facemask failed to improve his hypoxia so non‐invasive bilevel positive airway pressure ventilation was commenced. An immediate review by an ear, nose and throat (ENT) specialist in the emergency department identified regrowth of tumour in the buccal cavity and flexible nasendoscopy was attempted but no laryngeal structures were identified due to a markedly reduced hypopharyngeal space and bleeding from the tumour site. In view of impending airway obstruction, awake tracheostomy under local anaesthesia was considered but deemed impossible owing to the extreme neck swelling and because the patient was unable to position himself appropriately. Following a discussion between ENT and anaesthesia consultants, it was agreed that tracheal intubation would be required before attempting tracheostomy. The patient was transferred to the operating room for advanced airway management.

Figure 1.

Photograph of the patient's face demonstrating gross oedema of the eyelids, cheeks, lips and neck.

On assessment of the airway, the Mallampati class was 4, the inter‐incisor distance was 1.5 cm, and the neck circumference was 55 cm. The patient was unable to flex or extend his neck. He was tachypnoeic (rate 35 breaths.min⁻¹); tachycardiac (rate 115 beats.min⁻¹); and distressed but fully conscious. We explained the proposed technique of awake tracheal intubation to the patient for the purposes of consent and to try to ensure a smooth procedural course with his cooperation. Monitoring was applied, including ECG, non‐invasive blood pressure and pulse oximetry. An arterial cannula was placed in his right radial artery.

We chose awake videolaryngoscopy as the primary approach. Airway topicalisation was undertaken using lidocaine 10% through a combination of direct spraying and a mucosal atomisation device (MAD Nasal, Teleflex, Morrisville, USA) advanced to the maximum possible point in the oral cavity. A total dose of 250 mg of lidocaine was used. Supplemental oxygen was supplied through a nasal cannula at 15 l.min⁻¹. Because the patient was unable to lie down, a conventional laryngoscopy position at the head of the bed was not possible, so a face‐to‐face approach was adopted. A C‐MAC videolaryngoscope (Karl Storz, Tuttlingen, Germany) with a size 4 Macintosh blade was advanced to the vallecula and then 2 ml of lignocaine 4% was sprayed onto the glottic area using the mucosal atomisation device. Bleeding from the tumour on the left side of oral cavity was noted. The epiglottis was viewed but the vocal cords and glottic opening could not be identified due to arytenoid oedema. At this time, the SpO₂ started dropping, reaching a nadir of 82%, therefore the videolaryngoscope was withdrawn and the patient re‐oxygenated. A second attempt was made with the videolaryngoscope and a bougie but this was unsuccessful. A third attempt was made with a flexible bronchoscope alone, but this was abandoned as bleeding from the tumour obscured the already limited field of vision.

A fourth attempt was made with the combined use of the flexible bronchoscope and videolaryngoscope. The flexible bronchoscope was loaded with a size 6.0 tracheal tube and a separate screen was prepared. We used the videolaryngoscope to retract the tongue and expand the oral cavity, thus improving the visual field. The flexible bronchoscope was then inserted via the mouth and manoeuvred into the glottic opening. Tracheal rings were seen, and the tube was advanced into the trachea uneventfully. Once adequate ventilation was confirmed with waveform capnography, general anaesthesia was induced with propofol 140 mg i.v. and cisatracurium 12 mg was administered i.v. for neuromuscular blockade. Due to highly distorted tissue planes, the tracheostomy procedure was technically challenging and took approximately 90 min to perform. Postoperatively, the patient was transferred to the intensive care unit where he remained stable.

Discussion

This case presented multiple challenges: airway obstruction with hypoxia; airway distortion due to massive neck swelling and oedema; a friable tumour in the oral cavity; and an inability to adopt an optimal position for airway management. Our patient therefore had predictors of difficult facemask ventilation, laryngoscopy, intubation, supraglottic airway placement and FONA. This led to a scenario where awake tracheal intubation was the only safe option. It was therefore vital that the techniques used were chosen judiciously and performed carefully. According to recent nomenclature proposed by the Difficult Airway Society (DAS), awake tracheal intubation (ATI) can employ flexible bronchoscopy (ATI:FB), videolaryngoscopy (ATI:VL) or FONA (ATI:FONA) [7], and these can be used in combination in complex cases such as ours.

Significant developments have taken place in the last two decades regarding equipment to improve glottic view. Videolaryngoscopy is increasingly used for both primary and alternative techniques for tracheal intubation. Due to the position of the video sensor towards the tip of the laryngoscope blade, the oral, pharyngeal and tracheal axes are not required to align as in direct laryngoscopy, which mitigates problems with cervical spine and temporomandibular joint mobility. Awake tracheal intubation using videolaryngoscopy has a comparable success rate (> 98%) and safety profile to ATI:FB [7].

We opted for awake videolaryngoscopy as the first choice in our case because nasendoscopy had failed in the emergency department, and because the presence of bleeding from a friable tumour can obscure the view when using a flexible bronchoscope. Using awake videolaryngoscopy, we were successful in seeing the oedematous epiglottis and arytenoid cartilages, but we could not view the vocal cords. We also attempted to blindly pass a bougie beyond the epiglottis but were unable to successfully manoeuvre it into the glottic opening.

Concurrent use of videolaryngoscopy and flexible bronchoscopy can help to achieve success in difficult tracheal intubation. A videolaryngoscope may help to open the oropharynx and facilitates identification of anatomical landmarks, while a flexible bronchoscope can function as a steerable bougie, thereby avoiding trauma to airway structures and facilitating passage through a distorted airway. Previous case reports have described versions of a combined technique. Saunders et al. describe videolaryngoscopy‐assisted flexible intubation in the context of tracheal tube exchange, emphasising the importance of combining techniques to ensure a visible airway throughout [8]. Greib et al. successfully performed tracheal intubation in 16 patients with a combination of a DCI videolaryngoscope (Karl Storz, Tuttlingen, Germany) and flexible bronchoscope [9]. Young et al. reported a case of successful airway management with combined use of a McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) and flexible bronchoscope in a morbidly obese patient with large goitre [10]. While these published reports describe combined videolaryngoscope and flexible bronchoscope use in anaesthetised patients, we were unable to find any prior reports regarding the awake use of a videolaryngoscope combined with a flexible bronchoscope in an airway emergency.

As this case demonstrates, the simultaneous use of a videolaryngoscope and a flexible bronchoscope is a viable option in the awake management of difficult airway and may improve the chances of successful intubation when single device has failed. While this case was our first experience of the combined technique, we suggest that it may be useful for anaesthetists to train in the use of this approach so that it may be effectively deployed should a similarly complex airway emergency arise in practice.