Although awake fiberoptic intubation (FOI) is the technique of choice for a patient with anticipated difficult mask ventilation and intubation, a systematic review and meta-analysis showed that awake videolaryngoscopic intubation has a shorter intubation time, similar success rate, and safety profile compared to awake FOI.1
For a patient with a bronchopleural fistula (BPF), independent lung ventilation (ILV) facilitates optimal ventilation of the normal lung and maintains lower airway pressures on the affected side, which decreases the risk of air leak.2
We present a case of a 77-year-old man with a known difficult airway, who was admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) secondary to pneumonia and right BPF.
Written informed patient consent was obtained for this case report. The manuscript adheres to the Enhancing the Quality and Transparency of Health Research (EQUATOR) guideline.
Our patient was evaluated in the high dependency unit for respiratory failure secondary to ARDS from pneumonia and right BPF. He was discharged from the ICU 5 days before, after treatment for right empyema and infected bile collection that were complications from a partial hepatectomy.
He was tachypneic (30 breaths/min) with blood pressure of 156/92 mm Hg and heart rate of 102/min. Arterial blood gas, performed on 15 L/min of oxygen, revealed hypoxemia with type 2 respiratory failure (pH 7.41, partial pressure of carbon dioxide in arterial [Paco2] 56 mm Hg, partial pressure of oxygen in arterial blood [Pao2] 100 mm Hg, base excess 9.1, oxygen saturation 97%, standard bicarbonate 31.9 mmol/L). He was seated upright, using his accessory muscles of respiration, and could only speak in short phrases. Chest auscultation revealed right basilar coarse crepitations. There was bubbling in the right chest tube system on coughing that was suggestive of a persistent BPF. A chest radiograph (CXR) showed increased bilateral air space opacities and effusions.
He had a Mallampati score of class III, restricted thyromental distance of 2 fingerbreadths, and multiple missing teeth with sunken cheeks.
The patient had a Cormack and Lehane grade 4 laryngeal view on direct laryngoscopy with a size 4 Macintosh blade, and a bougie was required for intubation during his partial hepatectomy. Mask ventilation was easy. From his previous ICU notes, we noticed that he had a grade 2b larynx on direct laryngoscopy and backward, upward, and rightward pressure on the larynx was required for intubation.
The discrepancy in laryngeal views between the 2 previous intubations in this patient could be explained by a difference in the operators’ experience levels.
We opted for awake intubation because of a likely difficult airway, the need to maintain spontaneous ventilation, and to avoid mask ventilation with positive pressure ventilation (PPV) in view of the BPF. In addition, we wished to avoid general anesthesia for rapid sequence intubation in this patient who was septic, because it could lead to hemodynamic instability.
Our first choice was intubation with a double-lumen endotracheal tube (DL ETT) using a direct laryngoscope. A videolaryngoscope was the backup. A fiberoptic bronchoscope (FOB) was also prepared if the vocal cords could not be visualized with the direct laryngoscope and videolaryngoscope. If there was difficulty in passing the DL ETT past the cords or hemodynamic or respiratory compromise, the plan would be intubation with a single-lumen endotracheal tube and an endobronchial blocker.
Our patient was positioned with the head of bed elevated at 30°. Preoxygenation was commenced using bag-valve-mask with oxygen flow at 15 L/min by the operator who stood on a stool at the back of the patient. Oxygen was also administered via nasal prongs at 4 L/min. PPV was avoided to prevent worsening of the right BPF. Oxygen saturation increased from 97% to 99%.
Three sprays of lidocaine 10% were directed at the posterior pharynx and 3 mL of 2% lidocaine was instilled via the transtracheal route. Sedation was withheld because the patient was cooperative and to avoid suppression of respiratory drive. The patient tolerated direct laryngoscopy well with minimal gagging. A grade 3 larynx was visualized. His oxygen saturation dropped to 85% which resolved when he was placed back on the bag-valve-mask.
A McGrath (Medtronic, Boulder, CO) videolaryngoscope with a size 4 Macintosh blade was used next. The epiglottis was floppy and long, obstructing the view of the larynx. The blade was repositioned posterior to the epiglottis, lifting it up to reveal a grade 2a larynx. Two sprays of 10% lidocaine were directed at the vocal cords, and a 37F left-sided DL ETT was inserted smoothly on the first attempt. A FOB was used to confirm the placement of the DL ETT and to visualize the inflation of the bronchial cuff.
ILV was instituted. The left lung was ventilated using airway pressure release ventilation (APRV). A suction catheter with 8 L/min of oxygen was passed down the tracheal lumen of the DL ETT for insufflation of the right lung. Intravenous remifentanil and propofol infusions were started for sedation and titrated to maintain spontaneous respiration.
Arterial blood gases showed improvement in ratio of the partial pressure of oxygen in arterial blood to the fraction of oxygen in inspired air (Pao2:Fio2), and CXR 1 day later showed decreased airspace opacity in left lung, which was suggestive of alveolar recruitment.
After 30 hours of ILV, he developed worsening respiratory acidosis, which resolved when ILV was stopped, and both lungs were ventilated with positive pressure. He was extubated 6 hours later and discharged home after 2 months of rehabilitation. The BPF resolved 1 month later.
Awake FOI is the technique of choice when there is anticipated difficulty with both mask ventilation and intubation.3 Increasing evidence shows that awake videolaryngoscopic intubation is as safe and faster than awake FOI. In a randomized controlled trial,4 awake videolaryngoscopic intubation (McGrath videolaryngoscope) was compared to awake FOI for patients with anticipated difficult intubation. There was no difference in time to tracheal intubation by experienced anesthesiologists.
A systematic review and meta-analysis1 (8 studies, 429 patients) comparing awake videolaryngoscopic intubation against awake FOI found that the time needed for tracheal intubation was shorter when videolaryngoscopy was used instead of FOB (−45.7 seconds; 95% confidence interval, −66 to −25.4 seconds; P < .0001). There was no significant difference in the failure rate, first-attempt success rate, patient satisfaction level, hoarseness, sore throat, or desaturation rate between the 2 techniques.
For DL ETT intubation in anesthetized patients, a systematic review and meta-analysis5 (12 studies, 1215 patients) comparing videolaryngoscopy against direct laryngoscopy concluded that videolaryngoscopy provided a higher success rate at first attempt for tracheal intubation (odds ratio 2.77 [95% confidence interval, 1.92–4.00]). The incidences of dental injuries and postoperative sore throat were lower with videolaryngoscopy compared to direct laryngoscopy. Although there was no significant difference in intubation time, videolaryngoscopy had a higher incidence of mal-positioned DL ETT.
In another study on DL ETT intubation in anesthetized patients6 with unexpected difficult views (Cormack and Lehane grade ≥ 2b) on direct laryngoscopy, the McGrath videolaryngoscope improved the glottic view by an average of 2 grades.
We attempted intubation with direct laryngoscopy first because it offers a direct line of sight and passage of the DL ETT if the glottis is visualized compared to a videolaryngoscope that provides an indirect glottic view. A McGrath videolaryngoscope was the backup plan to provide better laryngeal view if the view was suboptimal on direct laryngoscope, which was the case. The disadvantage of videolaryngoscopy compared to direct laryngoscopy is that the oral-pharyngeal-laryngeal axes do not have to be aligned for glottic visualization which may make it difficult to pass the DL ETT through the glottis. Our third choice was the FOB which can be directed through the airway to visualize the glottic opening. However, the passage of the bulky DL ETT past the supraglottic structures cannot be visualized with the FOB sited in the trachea, whereas a videolaryngoscope can visualize supraglottic passage of the DL ETT. If glottic visualization with a videolaryngoscope is adequate but the DL ETT cannot be guided into the trachea, a FOB (placed through the bronchial lumen) can be used as a directable stylet under videolaryngoscopic guidance to reach the glottis and intubate the trachea.7
Guidelines for management of intubation in critically ill adults8 recommend that awake intubation should only be attempted by skilled and experienced clinicians. Our operator was an anesthetic senior resident with 5 years of airway management, including the use of videolaryngoscopic intubation and DL ETT. He was supervised by a senior consultant.
We opted for ILV. The left lung was ventilated using APRV for alveolar recruitment and this mode also allowed the patient to breathe spontaneously. Oxygen was delivered via insufflation to the right lung with the BPF and PPV was not applied to avoid exceeding the critical opening pressure of the fistula which can result in air leak.2
We used a DL ETT for ILV.9 The placement of a DL ETT may be challenging in a difficult airway7 because DL ETT is more rigid and larger compared to single-lumen tube. An alternative would be a single-lumen tube with an endobronchial blocker10,11 which may minimize the risk of loss of airway and/or trauma.7 However, bronchial suctioning and ventilation of the ipsilateral lung with the endobronchial blocker would be impossible.
To our knowledge, this is a first reported case of successful videolaryngoscope-assisted DL ETT intubation in an awake patient.
Name: Qing Yuan Goh, MD.
Contribution: This author helped manage the case, and write the article.
Name: Andrew Kong, MD.
Contribution: This author helped supervise the case, and proofread the article.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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