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LETTERS TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 7  |  Page : 600-602  

Paediatric ventilating bougie a rescue device in an unanticipated difficult mask ventilation in a patient with an impacted foreign body


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Command Hospital (SC) Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication12-Jul-2019

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command) Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_152_19

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How to cite this article:
Singh S, Lahareesh BL, Sud S, Dwivedi D. Paediatric ventilating bougie a rescue device in an unanticipated difficult mask ventilation in a patient with an impacted foreign body. Indian J Anaesth 2019;63:600-2

How to cite this URL:
Singh S, Lahareesh BL, Sud S, Dwivedi D. Paediatric ventilating bougie a rescue device in an unanticipated difficult mask ventilation in a patient with an impacted foreign body. Indian J Anaesth [serial online] 2019 [cited 2019 Jul 20];63:600-2. Available from: http://www.ijaweb.org/text.asp?2019/63/7/600/262606



Sir,

Aerodigestive impacted foreign bodies (FBs) of the airway have been described in literature, with FBs in the pharyngoesophageal region (86.2%) being the commonest and impacted meat being the most frequent FB in adults.[1] Removal of an impacted food particle can present as a case of difficult mask ventilation (DMV) or difficult intubation (DI) or both, which may be due to FB itself or due to the patient's factors.[2]

A 47-year-old male weighing 70kg, (BMI-24.2kg/m2) presented with cough, chocking sensation, dysphagia and dyspnoea of 72 hours duration after the consumption of chicken dish. Despite his negative initial examination by tongue depressor, Hopkins rod and fiberoptic laryngoscopy, patient continued to be symptomatic. X-ray of the neck and non-contrast CT scan confirmed a 3cm long and 2cm wide FB in the right pyriform fossa. The patient was planned for retrieval of the FB under general anaesthesia. Preoperative assessment was essentially normal with only presence of humped nose.

Preoperative consent and nil per oral (NPO) status were confirmed. Standard monitoring ensued. Patient was preoxygenated for five minutes and general anaesthesia (GA) was induced with I.V fentanyl 100 μg and propofol 140mg and adequacy of mask ventilation (MV) was checked which was inadequate. Despite the use of airway manoeuvres, airway adjuncts and change over to two person/four hand technique, difficulty of MV continued and grade4 stage of DMV developed with rapid desaturation with oxygen saturation (SpO2) falling from baseline of 99% to 70%. As a rescue measure laryngeal mask airway (LMA) size 4 was placed, and adequacy of ventilation was confirmed. Once the oxygen saturation improved, injection atracurium 0.5mg/kg I.V was administered and laryngoscopy revealed a Cormack Lehane gradeIII. In wake of difficult mask ventilation and difficult intubation LMA was reinserted and adult Ambu® aScope™ 3 Regular was inserted along with the paediatric bougie with ventilating port as the inner diameter of the LMA did not allow the adult bougie [Figure1]. Paediatric bougie was placed beyond the vocal cords under fiberoptic vision and oxygenation continued while LMA and Ambu® aScope™ 3 Regular were removed as a single unit. A, 7.5mm cuffed flexo-metallic endotracheal was rail-loaded over gum elastic bougie into trachea. FB was extricated in two pieces by the ENT surgeon using rigid laryngoscope. The perioperative period was uneventful and patient was extubated on table.
Figure 1: A representative picture showing Laryngeal Mask Airway as a conduit for Paediatric Ventilating Bougie and Ambu ® aScope TM as being utilised clinically in the patient

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The patients of impacted FB can pose a situation of DMV or difficult intubation (DI) or both with incidence of DMV being (l.4%) and impossible MV (0.15%).[2] The humped nose was the cause of DMV in our case which perhaps resulted in poor mask seal with leakage of gases. The aetiology of DMV includes presence of large tongue/epiglottis, beard, airway oedema, BMI >26kg/m2, obstructive sleep apnoea, laryngospasm, bronchospasm, irradiated neck and edentulous status.[3] Role of supraglottic airway as per recommendations given by All India Difficult Airway Association (AIDAA) in the year 2016 cannot be negated in the DMV scenarios.[4] The innovations like using paediatric ventilating bougie judiciously under direct fiberoptic vision through LMA as a conduit has helped in tiding over the crisis of potential difficult intubation with DMV patients without compromising the oxygenation.

To conclude the anaesthesiologist should have a high index of suspicion for DMV in patients with humped nose as it can lead to incomplete mask seal and ineffective mask ventilation leading to rapid desaturation of patient. Various airway adjuncts both adult and paediatric when present in difficult airway cart can come handy in securing airway when faced with the condition of DMV/DI.[5]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kamath P, Bhojwani KM, Prasannaraj T, Abhijith K. Foreign bodies in the aerodigestive tract—A clinical study of cases in the coastal belt of South India. Am J Otolaryngol 2006;27:373-77.  Back to cited text no. 1
    
2.
Orbany ME, Woehlck HJ. Difficult mask ventilation. Anesth Analg 2009;109:1870-80.  Back to cited text no. 2
    
3.
Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy. Anesthesiology 2013;119:1360-9.  Back to cited text no. 3
    
4.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India difficult airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 4
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5.
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:82748.  Back to cited text no. 5
    


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