Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 2337  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 8  |  Page : 677-678  

Time to include video laryngoscope as a tool for extubation in difficult airway cases!


1 Department of Anaesthesiology and Critical Care, INHS Asvini, Colaba, Mumbai, Maharashtra, India
2 Department of Anaesthesiology and Critical Care, Reliance Hospital, Navi Mumbai, Maharashtra, India
3 Department of Anaesthesiology and Critical Care, Command Hospital (Southern Command), Sholapur Road, Pune, Maharashtra, India

Date of Web Publication9-Aug-2019

Correspondence Address:
Dr. Vidhu Bhatnagar
Department of Anaesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba - 400 005, Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_249_19

Rights and Permissions

How to cite this article:
Bhatnagar V, Jinjil K, Dwivedi D. Time to include video laryngoscope as a tool for extubation in difficult airway cases!. Indian J Anaesth 2019;63:677-8

How to cite this URL:
Bhatnagar V, Jinjil K, Dwivedi D. Time to include video laryngoscope as a tool for extubation in difficult airway cases!. Indian J Anaesth [serial online] 2019 [cited 2019 Oct 19];63:677-8. Available from: http://www.ijaweb.org/text.asp?2019/63/8/677/264198



Sir,

Tracheal extubation is a critical time and a high-risk procedure. Exaggerated reflexes like laryngospasm and bronchospasm can lead to hypoventilation, hypoxia and negative pressure pulmonary oedema causing catastrophe on operating table post a successful surgery. On the other hand, inadequate airway reflexes can lead to aspiration.[1],[2] Extubation for patients who have undergone procedures on vocal cords is a tricky task due to airway injury and risk of laryngospasm due to the injury itself or from blood trickling. Now, there are guidelines laid down for extubation, both in routine and difficult cases, but these do not have a defined role for videolaryngoscopes.[3]

Here, we would like to highlight the use of video laryngoscope (King Vision™ aBlade Video Laryngoscope from manufacturer AMBU) as a viable and alternative tool for safe extubation in 4 patients presenting with glottic and supraglottic pathology, in place of conventional laryngoscopy with Macintosh blade. Our 4 cases were in age group 25-60 years; presented for biopsy of vocal cord growth in three cases and supraglottic growth in one case, respectively. 2 patients were accepted in American Society of Anaesthesiology physical status class II and the remaining two in class III. A plan for difficult airway was prepared and patients were counselled and informed consent taken. Since the patients had presented for biopsy, the airway plan was intubation and extubation under vision. All four patients were intubated using channelled video laryngoscope (King Vision™ aBlade Video Laryngoscope) and the surgery went off uneventfully.

The challenge was to achieve a safe extubation of adequately awake patients, under direct visualisation of glottis with stable haemodynamics. This comes under limb 3 of the AIDAA difficult extubation guidelines.[3] After reversal of residual neuromuscular blockade, and once adequate tidal volume was achieved on pressure support ventilation, sevoflurane was discontinued. The leak test was performed in each case and once leak test was established, the trachea were extubated using King Vision™ aBlade Video Laryngoscope. To avoid any haemodynamic changes and possible trauma to the airway, extubation was performed under cover of intravenous lignocaine 1 mg/kg over 2 minutes. The use of video laryngoscope established complete visualisation of glottic aperture. The Endotracheal Tube (ETT) was removed till just above the vocal cords and cords were observed for collapse or any fresh bleeding for 30 seconds before complete removal of the ETT. There was no incidence of airway trauma, re-intubation, hypoxia or post extubation loss of airway in any of our four cases. Randomised controlled trial by Priyanka AS et al. demonstrated successfully the mobility of the vocal cords by two different video laryngoscopes in patients undergoing major neck and thyroid surgeries.[4]

A fine assessment of the glottic aperture was provided by video laryngoscope with an optimal visualization of peri epiglottic structures and glottic aperture during the actual course of extubation. However, always remember reintubation of a failed extubation in such scenario renders intubation difficult and one has to switch immediately to difficult airway algorithm.

Attempt to bring these cases to light was to enable larger studies to assess the feasibility of using video laryngoscope assisted extubation in more difficult airway scenarios and later to look in to the possibility of inclusion of video laryngoscope in the difficult airway guidelines. It can come as an alternate tool in the algorithm wherever AEC or FOB are recommended [Figure 1].
Figure 1: AIDAA extubationguidelines: place where to include the video laryngoscope

Click here to view


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: A collective task force facilitated by the ACCP, AARC, and the ACCCM. Chest 2001;120(6 Suppl):375S-95S.  Back to cited text no. 1
    
2.
Cook TM, Woodall N, Frerk C, Fourth National Audit P. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth 2011;106:617-31.  Back to cited text no. 2
    
3.
Kundra P, Garg R, Patwa A, Ahmed SM, Ramkumar V, Shah A,et al. All India difficult airway association 2016 guidelines for the management of anticipated difficult extubation. Indian J Anaesth 2016;60:915-21.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Priyanka AS, Nag K, Hemanth Kumar VR, Singh DR, Kumar S, Sivashanmugam T. Comparison of king vision and truview laryngoscope for postextubation visualization of vocal cord mobility in patients undergoing thyroid and major neck surgeries: A randomized clinical trial. Anesth Essays Res 2017;11:238-42.  Back to cited text no. 4
[PUBMED]  [Full text]  


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed384    
    Printed0    
    Emailed0    
    PDF Downloaded71    
    Comments [Add]    

Recommend this journal