Portal de Periódicos da CAPES

Combined technique using videolaryngoscopy and Bonfils for a difficult airway intubation

2012; Elsevier BV; Volume: 108; Issue: 2 Linguagem: Inglês

10.1093/bja/aer471

1471-6771

André van Zundert, Barbe Pieters,

Anesthesia and Sedative Agents

Editor—A difficult tracheal intubation can sometimes still be a problem, even if one has taken all precautions such as the evaluation of premetrics of a difficult airway, difficult airway trolley, and help from additional qualified personnel. The BURP manoeuvre1Takahata O Kubota M Mamiya K et al.The efficacy of the 'BURP' maneuver during a difficult laryngoscopy.Anesth Analg. 1997; 84: 419-421Crossref PubMed Google Scholar is usually the first technique applied when laryngoscopy reveals a Cormack and Lehane grade III or IV, followed by the use of a number of adjuncts (gum elastic bougie, stylet) or different approaches of the airway (e.g. fibreoptic intubation, supraglottic airway, videolaryngoscopy). Nevertheless, even when all the above techniques have been applied properly, tracheal intubation still can be very challenging in the rare event that no part of the glottic entrance, nor the epiglottis can be seen. We report our experience with a 45-yr-old woman (165 cm, 128 kg, BMI 48 kg m−2, ASA class II, Mallampati grade IV, thyromental distance 51 mm, mouth opening 41 mm, short restricted neck) who presented for bariatric surgery (sleeve resection) under general anaesthesia. She had a past medical history of hypertension and diabetes mellitus and during a previous operation for removal of the right ovary (in another hospital), she had a prolonged and very difficult intubation, which eventually was successful using the LMA-Fastrach® as a conduit for tracheal intubation. After discussing the anaesthetic options, the team and the patient agreed to proceed with general anaesthesia. After preoxygenation for 4 min, i.v. fentanyl 5 µg kg−1 and propofol 2.5 mg kg−1 i.v. was administered. Before intubation, the lungs were manually inflated using face mask ventilation without problems. Rocuronium 0.1 mg kg−1 was given i.v. and mask ventilation continued until the conditions were suitable for intubation of the trachea. This induction is in accordance with the routine practice in our hospital for bariatric surgical patients with the presence of the difficult airway trolley in the room. As we have been using the videolaryngoscope (C-MAC® videolaryngoscope, Karl Storz, Tuttlingen, Germany) for almost 3 yr as our standard intubation technique, we also used it in this particular patient, revealing a Cormack–Lehane grade III, whereas the classic laryngoscope showed a grade IV. We easily intubated the trachea by using a combined technique, that is, the videolaryngoscope used to achieve the best possible view and space of the laryngeal inlet for the insertion and manoeuvring of the Bonfils® (Karl Storz, Tuttlingen, Germany), which was pre-loaded with the tracheal tube. There is enough room next to the C-MAC® to allow easy insertion of the Bonfils® intubating fibrescope.2Corso RM Gambale G Piraccini E Petrini F Emergency airway management using the Bonfils intubation fiberscope.Intern Emerg Med. 2010; 5: 447-449Crossref PubMed Scopus (4) Google Scholar 3Mazères JE Lefranc A Cropet C et al.Evaluation of the Bonfils intubating fibrescope for predicted difficult intubation in awake patients with ear, nose and throat cancer.Eur J Anaesthesiol. 2011; 28: 646-650Crossref PubMed Scopus (22) Google Scholar Once the Bonfils® had entered the trachea, the tracheal tube was placed in the correct position. We organized it in such a fashion that both views were brought together on one monitor which normally is used by the surgeons (Fig. 1), so that the intubation procedure could be seen by the whole team. This combined technique can be used for difficult tracheal intubation and can be one of many alternative routes to secure a safe airway for which anesthesiologists should be trained in. The videolaryngoscope can also be helpful in presenting a better view for rigid bronchoscopy (respiratory physicians) or for ENT surgeons, who wish to inspect the oropharynx and larynx. None declared. Download .zip (.0 MB) Help with zip files