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LETTER TO EDITOR
Year : 2018  |  Volume : 62  |  Issue : 11  |  Page : 910-911  

Awake fibreoptic bronchoscopy guided intubation – significance of sitting position


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication2-Nov-2018

Correspondence Address:
Dr. Kanil Ranjith Kumar
Room No. 5011, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_300_18

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How to cite this article:
Kumar KR, Selvam SR, Priya B. Awake fibreoptic bronchoscopy guided intubation – significance of sitting position. Indian J Anaesth 2018;62:910-1

How to cite this URL:
Kumar KR, Selvam SR, Priya B. Awake fibreoptic bronchoscopy guided intubation – significance of sitting position. Indian J Anaesth [serial online] 2018 [cited 2018 Dec 10];62:910-1. Available from: http://www.ijaweb.org/text.asp?2018/62/11/910/244834



Sir,

Vallecular cyst can cause difficulty in mask ventilation, laryngoscopy and intubation.[1] There are reports of cannot intubate and cannot ventilate situation after induction of anaesthesia due to undiagnosed vallecular cyst. Aspiration of the cyst, rigid bronchoscope, stylet, bougie, trans-tracheal jet ventilation and Mc-coy laryngoscope have been used for airway management in vallecular cyst.[2],[3] In diagnosed cases, awake fibreoptic bronchoscopy (FOB) guided intubation is the ideal method to secure airway. We highlight here the significance of position during awake FOB in a patient with a large vallecular cyst.

A 58-years male patient, was scheduled for excision of a vallecular cyst under general anaesthesia. He presented with mass sensation in the throat and voice change. He had no difficulty in breathing or lying in supine position. Indirect laryngoscopy and nasal fibreoptic laryngoscopy (FOL) revealed a vallecular cyst of 3 × 3 cm. Preoperative CT-neck showed a cystic lesion from vallecula pushing the epiglottis backwards and reaching up to posterior pharyngeal wall [Figure 1].
Figure 1: Preoperative computed tomography image showing large vallecular cyst

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Awake nasal FOB guided intubation was planned and the same was explained to the patient. Patient received inj. Glycopyrrolate 0.2 mg intramuscularly before shifting to operation theatre. In the operation room, 2 drops of xylometazoline was added to each nostril and inj. Midazolam 1 mg was given. Airway anaesthesia was achieved by bilateral superior laryngeal nerve block with 2% lignocaine 2 ml on each side and a trans-tracheal injection with 4 ml of 2% lignocaine. Lignocaine jelly was used for topicalisation of nasal cavity. With the patient in the supine position, FOB was done from the head end of the patient through right nostril. The patient was asked to extend the neck and protrude the tongue out; even then no space was available to negotiate the FOB around the mass. However the preoperative FOL picture showed adequate space between the mass and posterior pharyngeal wall. Understanding the effect of position on the mass, patient was made to sit on the operation table. FOB was repeated with anaesthesiologist standing in front of the patient. In sitting position there was enough space behind the mass, which increased further when he protruded the tongue out. A preloaded nasal RAE tube was guided into the trachea uneventfully. Patient was cooperative and comfortable throughout the procedure.

In diagnosed cases of vallecular cyst, awake FOB is preferred because after induction of anaesthesia the cyst might fall over the glottic aperture leading to difficult mask ventilation and intubation.[1] Anaesthesiologists are conventionally trained to perform FOB from head end of the table with the patient in the supine position. But in sitting position, anaesthesiologist will be standing in front and facing the patient. By convention FOB is held with the left hand and supported over the shoulder. The image obtained while doing FOB from front will be 180° rotated of that seen with direct laryngoscopy or with FOB done from head end. So there might be an initial difficulty in orientation. Substitution of deeper plane of sedation and emergency airway management will be difficult in this position. On other hand sitting position facilitates gravity depended drainage of secretions and downward movement of FOB towards the glottis without much manipulation.[4] Awake FOB guided intubation in sitting position is preferred for those who cannot tolerate supine position due to airway or respiratory compromise. There are previous reports on FOB in sitting position for airway compromising thyroid swellings.[4],[5] In our case effect of gravity on the mass led to the difficulty could have been avoided by FOB in sitting position at first attempt. Apart from conventional training of FOB in supine position, anaesthesiologists should be familiar with FOB in the sitting position.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Jayaram K, Gurajala I, Diddi S, Ramachandran G. Unrecognized epiglottic cyst: Cause of difficult mask ventilation. J Anaesthesiol Clin Pharmacol 2015;31:566-7.  Back to cited text no. 1
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2.
Yuce Y, Uzun S, Aypar U. Asymptomatic vallecular cyst: Case report. Braz J Anesthesiol 2013;63:419-21.  Back to cited text no. 2
    
3.
Walshe CM, Jonas N, Rohan D. Vallecular cyst causing a difficult intubation. Br J Anaesth 2009;102:565.  Back to cited text no. 3
    
4.
Saxena KN, Kumar S, Taneja B, Gaba P. Awake fibreoptic intubation in the sitting position in a patient with a huge Goitre. Case Rep Anesthesiol 2011;2011:352672.  Back to cited text no. 4
    
5.
Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, et al. A rapidly enlarging neck mass: The role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627-9.  Back to cited text no. 5
    


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