Intubating laryngeal mask airway-A lifesaver during accidental intraoperative extubation in a case of difficult airway.

Sir,

The unanticipated difficult airway, a common clinical problem encountered by all anesthesiologists, is probably the most important cause of major anesthesia-related morbidity.[1] The American Society of Anesthesiologists published a difficult airway management algorithm more than a decade ago. Lately, devices such as intubating laryngeal mask airway (ILMA) and combi tube have also been included. Recently, we encountered a case of accidental extubation intraoperatively where ILMA proved to be a lifesaver.

A 45-year-old adult male, ASA grade 1, chronic smoker, and tobacco chewer, was taken up for esophagoscopy for impacted piece of fish bone. His airway examination revealed mouth opening of hardly two fingers, Mallampati grading III with normal thyromental, sternomental distances and neck movements. All his preoperative investigations were within normal limits. He was taken up on operating table, all monitors were attached, an intravenous access was secured, and was nebulized with 4% xylocaine for fiberoptic intubation. Awake fiberoptic intubation (AFOI) was performed using “spray as u go” technique. After successful intubation, patient was given propofol and was paralyzed; anesthesia was maintained with O2, N2O, and sevoflurane. Surgery was started but the piece of bone was impacted in the upper end of esophagus and surgeons were having a difficult time trying to remove it. There was also inadvertent trauma to the oral cavity associated with bleeding. Around 20 minutes after beginning of surgery, the surgeons accidently dislocated the endotracheal tube. The surgery was immediately stopped and mask ventilation started after oral suctioning. But now, fiberoptic intubation was impossible. Direct laryngoscopy now revealed a Cormack and Lehane grade IV view. Meanwhile, the patient developed severe bronchospasm and his SpO2 started falling to 85%. Immediately, injection deriphyllin and hydrocortisone were administered intravenously along with two puffs of salbutamol. Intubation using gum elastic bougie failed. Intubation was tried using ILMA which was successful only on third attempt. His bronchospasm finally resolved after aminophylline infusion. Surgery was again started and finished successfully after 20 minutes.

Managing a difficult airway is a challenge even to an experienced anesthesiologist. Intraoperative accidental extubation in such cases, associated with severe bronchospasm, can be catastrophic. Though fiberoptic intubation is a boon for cases with anticipated difficult airway, it has a very high incidence of failure if there are secretions or blood in the oral cavity. In our case, though fiberoptic intubation was successful in the first attempt, it was not possible to reintubate the patient using the same technique with blood and edema in the oropharynx.

The ILMA was designed to facilitate both extraglottic ventilation and tracheal intubation. There are several studies reporting that the ILMA is a remarkable device for failed or difficult intubation with no serious complications.[2] Joo et al. account ILMA as a useful device in the management of patients with difficult airways and as a valuable alternative to AFOI when AFOI is contraindicated or in the patient with the unanticipated difficult airway.[3] It has proved to be effective when used by experienced anesthesiologists in both in-hospital and out-of-hospital settings[4] and is responsible for decreasing morbidity and mortality in many cases of difficult airway, as it proved to be a lifesaver in our case.