Indian Journal of Anaesthesia

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!


Vidhu Bhatnagar1, Kavitha Jinjil2, Deepak Dwivedi3,  
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

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




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;63:677-678


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 2020 Aug 4 ];63:677-678
Available from: http://www.ijaweb.org/text.asp?2019/63/8/677/264198


Full Text



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}

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1MacIntyre 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.
2Cook 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.
3Kundra 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.
4Priyanka 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.