Video laryngoscope as an assist tool in lateral position laryngoscopy.

Difficult airway is one of the most challenging situations invariably encountered in modern anesthesia practice and requires a high level of skill. This case report highlights the use of video laryngoscopy as an assist device for lateral position intubation in a patient with a large lumbar mass who was unable to lie supine. This case emphasis the significance of careful approach to planning and preparation in the management of airway in such a case.

INTRODUCTION

Management of difficult airway presents a great challenge for anesthesiologist. The incidence of difficult intubation is around 8% and 9%.[1] Difficulties can be due to anatomical variations/abnormalities of the airway or inability of the patient to obtain an optimum position for laryngoscopy and intubation. Proper positioning is essential for conventional laryngoscopy, best achieved with patient supine. However, sometimes one may encounter a clinical situation where the supine position is not possible, and one has to secure the airway in positions other than supine[2345] which poses a challenge to even an experienced anesthesiologist. We hereby report a case with patient's inability to lie down supine due to a large protruding lumbar mass, managed with lateral position intubation.

CASE REPORT

An American Society of Anesthesiologists Class-II, a 57-year-old man, weighing 73 kg with controlled hypertension, presented at preanesthestic clinic for excision of a gradually enlarging large mass (35 cm × 30 cm in size) in the right lumbar region [Figures 1 and 2]. On assessment patient reported that he was unable to lie down supine and could sleep only in the left lateral position. The growth was well defined, globular in shape with bossulated surface and firm in consistency. Airway assessment revealed adequate mouth opening, neck extension, and flexion with loose upper incisors and Mallampati score of 3.

Figure 1

Patient in sitting position

Figure 2

Patient in left lateral position

As the patient was unable to lie down in supine position, intubation was planned in latreral position. The procedure was explained to the patient and a written informed consent obtained. Patient was made to lie down in the left lateral position. Head was supported with a firm pillow. Standard monitoring devices were attached, and an intravenous line (i.v.) was secured with 18-gauze cannula.

The patient was premedicated with i.v. glycopyrolate (0.01 mg.kg-1), i.v. midazolam (0.02 mg.kg-1), i.v. ondansetron 4 mg, and i.v. fentanyl (1 μg.kg-1). After preoxygenating with 100% oxygen, the patient was induced with 5% sevoflurane. Spontaneous respiration was maintained. Check laryngoscopy was performed with video laryngoscope (model-C MAC, Karl Storz, Tuttlingen Germany blade size D). Comarck–lehane grade two was observed. The patient was intubated with 8.5 mm ID orotracheal cuffed endotracheal tube (ETT) after giving i.v. succinylcholine (1.5 mg.kg-1). Vocal cords and ETT was visualized till the inflation of the pilot balloon. The breathing circuit was then attached; proper ETT placement was confirmed by reservoir bag movements, bilateral breath sounds, and capnography. Anesthesia was maintained with O2, N2O, and sevoflurane. Muscle relaxation was maintained with intermitted i.v. vecuronium (0.08 mg.kg-1). Intraoperative period was uneventful. Postoperatively, the patient was reversed with i.v. glycopyrolate (0.01 mg.kg-1) and i.v. neostigmine (0.05 mg.kg-1) after return of spontaneous respiratory efforts. The patient was extubated fully awake. The postoperative course remained uneventful. The patient was discharged on 7th postoperative day.

DISCUSSION

Airway management is one of the most important skills required of anesthesiologist. Failed or difficult endotracheal intubation still remains a major cause of morbity and mortality even in current modern day anesthesia practice. To reduce the incidence of this life-threatening situation, the anesthesiologist should always perform a careful preoperative evaluation and formulate an action plan well in advance if a difficult airway is anticipated.[6]

Supine position is the optimum position for laryngoscopy and intubation but sometimes in unavoidable situations, lateral decubitus position intubation may deem necessary.

Lateral position in itself is a difficult intubation scenario, being not a routine and ideal position for laryngoscopy. In a patient with back masses putting the patient supine using pillows or making hole in the operating table[7] may be the option but the availability of video laryngoscope in our institution prompted us to utilize it to our advantage.

The awake fibreoptic intubation remains the gold standard for anticipated difficult intubation. Use of flexible stylet with direct laryngoscopy,[2] intubating laryngeal mass airway (LMA),[3] lightwand,[4] and GlideScope[5] has been described in literature to secure airway in lateral decubitus position. Video laryngoscope is an advanced version of coventional direct laryngoscope offering the anesthetist a better primary laryngoscopy tool.[8]

Although LMA and other supraglottic devices are essential tools and may prove lifesaving in difficult airway situation but they still fall short of the gold standard of a secure airway. Intubating LMA may help, but visual confirmation is not possible, it might not be possible to pass a larger size ETT through it, and chances of displacement are higher. Video laryngoscopes have an easier learning curve as compared to flexible fiberoptic laryngoscopes due to their similar structure as of conventional laryngoscope. It is a good alternative associated with much wider and better visualization of laryngeal view than conventional and flexible fiberoptic laryngoscopy.[910] Anesthesia assistant can better assist the intubating anesthesiologist by simultaneously visualizing the cord structures and applying external laryngeal manipulation accordingly if needed. It may be possible to pass an appropriate large sized/small sized ETT more easily after visualizing and determining the size of glottis on the monitor. Thus, video laryngoscope can prove to be an important intubation assist device in uncommon airway scenario and should be kept as one of the options.

CONCLUSION

This case report emphasis that routine airway assessment does not preclude the difficulties that can arise due to difficult positioning. It always helps to anticipate and be prepared. Recognize difficulties at an early stage. In a planned difficult intubation scenario always evaluate your options. Video laryngoscope is an important assist device and may be useful in certain difficult airway situations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest