We would like to describè a case of difficult airway management in a patient with acromegaly. A 52-year-old male (weight 93 kg, height 185 cm), ASA physical status II, was scheduled to undergo a video assisted thoracoscopy for resection of cysts from the upper lobe of the right lung. The results of the pre-operative airway assessment were as follows: Mallampati score 3 , interincisor gap (mouth opening) 3.5 cm with forward protrusion of the upper incisors beyond the lower incisors and with prominent upper teeth, head and neck mobility 90°  and thyromental distance 7.0 cm .
Anaesthesia was induced with propofol 2.5 mg kg−1, fentanyl 2 μg kg−1, suxamethonium 1.5 mg kg−1. The patient was adequately oxygenated by using positive pressure facemask ventilation. Tracheal intubation under direct laryngoscopy was found to be difficult, because three intubating attempts failed to intubate the trachea . Afterwards an intubating laryngeal mask (ILM) (size 5) was placed easily and a straight reinforced 8.0 mm Rusch tracheal tube (TT) preloaded with a prototype illuminated flexible catheter (IFC)  was inserted successfully. The device of the IFC consists of a completely flexible thin plastic catheter without any metallic component, which at its distal end comprises a bulb of adequate brightness fixed with atoxic glue and silicone. During insertion of the TT via the ILM, we noted a bright glow in the midline of the neck at the level of the laryngeal prominence that continued the downward movement, indicating correct placement of the TT in the trachea . The cuff of the TT was inflated and correct placement was judged by chest auscultation and capnography. The ILM was then deflated and removed. A frozen nasogastric tube (NGT) was passed carefully through the lumen of the TT and the TT was withdrawn. The stylet of a left-sided double lumen endobronchial tube (EBT) 39 French was removed and the IFC was inserted in the tracheal lumen of the EBT in such a way that the bulb protruded from its tip. Afterwards the bronchial lumen of the EBT was rolled along the NGT and the EBT was inserted into the mouth with the distal curvature initially concave anteriorly. The EBT was advanced carefully by noting the glow of the IFC in the midline of the neck. When the glow was noted under the laryngeal prominence the NGT was removed and the EBT was rotated 90 degrees toward the left side to allow endobronchial intubation. Chest auscultation proved successful positioning of the EBT and one-lung anaesthesia was proceeded uneventfully.
The ILM was used as an aid for insertion of a tracheal guide in this case of difficult intubation and the IFC facilitated the precise localization of the tip of the tracheal lumen of EBT to the point that it should be rotated in order to achieve a successful endobronchial block.
G. S. VOYAGIS
Department of Anaesthesiology, Sotiria and Gennimatas Hospitals, Athens, Greece
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