Oral gastroscope-guided bougie insertion and endotracheal intubation.

Sir,

Upper gastrointestinal (GI) endoscopy is both a diagnostic and therapeutic procedure. Some of these procedures are usually done under deep sedation with the airway unprotected.[1] Endoscopy suites are usually situated far away from the main operation theatre complex with limited anaesthetic facilities. Therefore, difficult airway patients undergoing endoscopy can pose a great airway challenge.[2] We present a case of difficult airway, where an oral gastroscope was used as an alternative to fibre-optic bronchoscope (FOB) in an endoscopy room.

A 40-year-old male belonging to American Society of Anesthesiologists physical status 1 was posted for upper GI endoscopy with enteral biopsy under intravenous sedation. The patient was a tobacco chewer for the past 20 years. On examination, he had restricted mouth opening of one and half finger only. Neck movements were normal and thyromental distance was more than 6 cm. Written and informed consent was obtained. Difficult airway cart was kept ready. The airway was nebulised with 4% lignocaine. Just before the procedure, four puffs of 10% lignocaine were administered. The patient was placed in the left lateral decubitus position and endoscopy was started. To assess difficulty in intubation, the gastroenterologist was asked to keep gastroscope at the level from where vocal cords can be seen clearly. A well-lubricated bougie was then inserted carefully right along the gastroscope [Figure 1a]. After the bougie tip was seen on the monitor, it was guided towards the patient's trachea [Figure 1b]. The bougie was inserted easily into the patient's trachea without any trauma and coughing. Our plan was to insert the bougie into the trachea using oral gastroscope followed by removal of the gastroscope and threading of endotracheal tube over the bougie, in case need arose. The bougie was then taken out quickly. Injection propofol 150 mg (intravenous) at incremental doses along with injection fentanyl 100 μg (intravenous) was administered. The procedure was uneventful without any other intervention.

Figure 1

(a) The insertion of bougie through the mouthguard right along the gastroscope. (b) Guiding bougie into the trachea while looking at the gastroscope monitor

Intubating a patient of difficult airway for procedures such as endoscopy may not be justifiable and, at the same time, giving sedation without securing the airway can be very challenging. We planned to sedate the patient and secure the airway with the help of an oral gastroscope, if at all required during the procedure. Plan B was to use flexible FOB for endotracheal intubation. Both oral gastroscope and flexible FOB have similar working principle. Oral gastroscopes have larger outer diameter (8–14 mm). Therefore, it is not possible to mount an endotracheal tube over the oral endoscope and thus cannot be used for endotracheal intubation. To overcome this difficulty, we had used bougie along with the oral gastroscope. Rigid and flexible nasal endoscopes have been used for the endotracheal intubation.[34] However, ubiquitous availability of nasal endoscopes at all the centres is questionable. Moreover, it requires the change of endoscope, which at times may be time-consuming as these nasal endoscopes need to be prepared before they can be used. The main advantage of our technique is that the patient can be intubated quickly in the same endoscopy position with the same endoscope. The disadvantage is the blind insertion of bougie initially until its tip is seen on the monitor, which can cause trauma to the oral structures. This can easily be taken care of by proper lubricating jelly application and careful insertion. To conclude, this simple technique can prove to be of great asset for an anaesthesiologist working in endoscopy suites where anaesthetic facilities are limited.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.