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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 1  |  Page : 87 Table of Contents     

Difficult Airway Management in A Case of Thalassaemia Major


1 Assistant Professor, Department of Anesthesia, PGIMER, Chandigarh., India
2 Senior Resident, Department of Anesthesia, AIIMS, New Delhi., India

Date of Acceptance10-Dec-2007
Date of Web Publication19-Mar-2010

Correspondence Address:
Neerja Bharti
Assistant professor, Department of Anaesthesiology and intensive care, PGIMER,Chandigarh-160012
India
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Source of Support: None, Conflict of Interest: None


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Difficult to ventilate, difficult to intubate cases are the most challenging to anaesthesiologists. We present a case of thalassaemia with difficult airway who underwent splenectomy surgery. The severe maxillary prominence with protruded upper incisors, limited mouth opening, depressed nasal bridge and narrow anterior nares posed a problem in mask ventilation and subsequent tracheal intubation. The patient was intubated successfully using fibreoptic bronchoscope aided with intubating laryngeal mask airway (Fastrach).

Keywords: Difficult airway; Thalassaemia; Anaesthesia


How to cite this article:
Bharti N, Devrajan J. Difficult Airway Management in A Case of Thalassaemia Major. Indian J Anaesth 2008;52:87

How to cite this URL:
Bharti N, Devrajan J. Difficult Airway Management in A Case of Thalassaemia Major. Indian J Anaesth [serial online] 2008 [cited 2020 Oct 25];52:87. Available from: https://www.ijaweb.org/text.asp?2008/52/1/87/60606


   Introduction Top


Anatomical characteristics of the airway contrib­ute to a substantial proportion of cases of difficult intu­bation. Inability to manage difficult airway has been re­sponsible for as many as 30% of the total deaths attrib­utable to anaesthesia [1] . Thalassaemias are haematological disorders characterized by abnormal haemoglobin with extra vascular haemolysis and ectopic marrow expan­sion leading to anaemia, splenomegaly and bony abnor­malities. Facial bone involvement causes hypertrophy of maxilla with obstruction of nasal passages. Though sta­tistical analysis revealed a significantly increased risk of difficult intubation among the thalassaemic patients with hypertrophy of maxilla [2] .

This patient was unique among the thalassaemic patients because the maxillary hypertrophy was not ac­companied by enlargement of the mandible. This resulted in narrowing of the submental space. So there was little space to displace the tongue. Moreover the protruding upper incisors prevented the proper alignment of the axes and hence the difficulty encountered with direct laryn­goscopy.


   Case report Top


A 24-year-old male patient, a known case of beta­thalassaemia major, of about 155 cm height and 45 kg weight, was posted for splenectomy. He was diagnosed to have thalassaemia at the age of as early as 8 years and was requiring blood transfusions twice a week for the past three years. He had also developed splenom­egaly leading to thrombocytopenia and leucopenia. Physi­cal examination showed a heart rate of 92 beats min -1 and a blood pressure of 110/70 mm Hg. He was pale and mildly icteric. He had hugely enlarged spleen ex­tending 15cm below the subcostal margin and hepatomagaly extending 4cm below the subcostal mar­gin. He had maxillary prominence and forward protru­sion of upper incisors. Nasal bridge was depressed and anterior nares were very much narrowed due to the en­croachment of hypertrophic maxillae [Figure 1].

Airway examination revealed an inter-incisor dis­tance of about 3cm and a Mallampatti grade of IV [Figure 2].

Laboratory investigations showed haemoglobin of 9 g.dl -1 , total leucocyte count (TLC) of 3300 cells.mm -3 and platelet count of 70,000 cells.mm -3 . Serum bilirubin was 6.5 mg.dl -1 . Liver enzymes, serum proteins, serum electrolytes, kidney function tests, X-ray chest and ECG were within normal limits. Coagulation profile was within acceptable limits with prothrombin time index of 75% and international normalized ratio of 1.5. Echocardiogram demonstrated an ejection fraction of 50% and normal wall motion of the ventricles. Ultrasound abdomen con­firmed the physical findings of hepatosplenomegaly.

Difficulty in ventilation and intubation was antici­pated. It was further complicated by the presence of potential risk of bleeding due to the presence of relative thrombocytopenia. As the patient was reluctant for un­dergoing awake endotracheal intubation, oral fibreoptic intubation after induction of anaesthesia was planned. Patient was fasted for 8 h before surgery and premedi­cated with 5 mg of oral diazepam 2 h before the ex­pected time of commencement of surgery.

On arrival in the operating room, routine monitors were applied to the patient for recording of heart rate, blood pressure and oxygen saturation. Patient was preoxygenated for three min and anaesthesia was in­duced with 70mcg of fentanyl followed by 80 mg of propofol. Initially mask ventilation seemed difficult due to poor mask fit, but improved to some extent after the insertion of oropharyngeal airway and gauze packing of the gap between cheek and mask. Anaesthesia was deep­ened with isoflurane in oxygen. Check laryngoscopy showed a Cormack Lehane grading of glottic visualisation as grade IV. A tracheal intubation via oral route was attempted using a Pentax 4.0 fibreoptic bronchoscope. After visualising the cords with little difficulty, an attempt was made to insert the endotracheal tube (size 7.0 mm) into the glottis through the fibrescope, but it could not be negotiated. Repeated attempts were avoided due to risk of bleeding. 50 mg succinylcholine was then adminis­tered intravenously and intubating laryngeal mask air­way (ILMA) size3 was placed to resume the ventila­tion. Once the gas exchange was found adequate. The fibreoptic bronchoscope was then inserted through the ILMA. After visualising the cord, the bronchoscope was passed to the glottis and subsequently 7.0 mm silicone ILMA tracheal tube was railroaded over the broncho­scope. Trachea was intubated in the first attempt itself with the aid of ILMA. After confirming tracheal intuba­tion with end tidal carbon-dioxide, ILMA was removed and the surgery commenced. Anaesthesia was main­tained with 50% nitrous oxide and isoflurane in oxygen. Controlled ventilation was facilitated by vecuronium. Analgesia was supplemented with morphine. Intraop­erative period was uneventful. The neuromuscular block­ade was reversed with neostigmine and atropine at the end of the surgery and the trachea was extubated when the patient was awake. Patient had no complication dur­ing postoperative period, and was discharged after three days.


   Discussion Top


Fibreoptic guided tracheal intubation is accepted as the gold standard in cases of suspected difficult intu­bation [1],[3] . However, upto 13% failure rate has been re­ported in literature [4] , mostly because of inability to pass the endotracheal tube over the fibrescope into the tra­chea. Failure occurs more frequently during oral intuba­tion and is related to impingement of ETT onto epiglottis, aryepiglottic folds, or corniculate cartilages [5] . Reposition­ing of tube is helpful but does not always improve the chances of success or may cause trauma to laryngeal structures [6] . Oral fibreoptic intubation was failed in this case probably because of the acute angulation between the laryngeal and pharyngeal axes. Though nasal fibreoptic intubation is technically easier and more suc­cessful than oral fibreoptic intubation, nasal intubation was not possible in this case because of the very narrow anterior nasal openings. The classic LMA could have been used to aid tracheal intubation by guiding a gum elastic bougie through the LMA into the larynx. Again it might prove rather difficult to railroad the endotracheal tube over gum elastic bougie. The same would hold true for the light-wand guided and retrograde intubations.

Recent studies showed that the success rate of intubation by using ILMA in patients with difficult air­way is comparable to fibreoptic intubation [7] . There are case reports where failed fibreoptic intubation was suc­cessfully managed with ILMA guided intubation [8] . ILMA was successful in this case because it aligns in a better way especially in patients with superior and anteriorly placed larynx. The ILMA created a conduit that pro­vided better conditions for intubation. We avoided blind intubation through ILMA to decrease failure rate and the chance of airway trauma. Joo et al [9] demonstrated 25% higher success rate of intubation via ILMA with fibreoptic bronchoscope guidance as compared to blind tracheal intubation. Another problem in the above case was the limited mouth opening contributed by the abnor­mal dentition. But it did not pose any problem for intuba­tion through ILMA. ILMA had been used successfully in patients with mouth opening as narrow as 25mm [10] .The added advantage of ILMA is - ILMA specific sili­cone made straight endotracheal tube. Standard (Portex) tracheal tube is relatively inflexible and tends to catch on anatomical structures such as arytenoids cartilages and vocal cords. However, the silicon made tube is both soft and flexible, and has a tapered end, thus reducing the gap between the fiberscope and the tube. There­fore, the ease of intubation is more with ILMA tube as compared with the standard tube [11] .

Submental intubation was reported [12] to avoid tra­cheostomy in a patient with beta thalassaemia major for maxillary and mandibular osteotomies. The anatomical deformities made nasal intubation impossible as in this patient.

This case illustrates that ILMA may be a useful adjunct to facilitate tracheal intubation in cases of diffi­cult or failed intubation. The ILMA has additional ad­vantage in 'difficult to ventilate' patients as it allows ven­tilation during tracheal intubation attempts.

 
   References Top

1.Benumof JL. Management of the difficult airway. Anesthesiol­ogy 1991; 75: 1087-110.  Back to cited text no. 1      
2.Voyagis G, Kyariakis KP. Homozygous thalassaemia and diffi­cult endotracheal intubation. Am J Hematol 1996; 52: 125-6.  Back to cited text no. 2      
3.Ovassapian A. Management of difficult airway. In: Ovassapian A (Ed.). Fibreoptic endoscopy and the difficult airway, 2nd ed. New York: Lippincott-Raven, 1996: 201-30.  Back to cited text no. 3      
4.American society of Anesthesiologists. Practice guidelines for man­agement of the difficult airway. Anesthesiology 2003; 98: 269-77.  Back to cited text no. 4      
5.Katsnelson T, Frost E, Farcon E, Goldiner P. When the tube will not pass over the flexible fibreoptic bronchoscope. Anes­thesiology 1992; 76: 151-2.  Back to cited text no. 5      
6.Maktabi MA, Hoffman H, Funk G and Robert P. Laryngeal trauma during awake fiberoptic intubation. Anesth Analg 2002; 95: 1112-4.  Back to cited text no. 6      
7.Langeron O, Semjen F, Bourgain J-L, Marsac A, Cros A-M. Comparison of the intubating laryngeal mask airway with the fibreoptic intubation in anticipated difficult airway manage­ment. Anesthesiology 2001; 94: 968-72.  Back to cited text no. 7      
8.Watson NC, Hokanson M, Maltby JR, Todesco JM. The intu­bating laryngeal mask airway in failed fibreoptic intubation. Can J Anaesth 1999; 46: 376-8.  Back to cited text no. 8  [PUBMED]    
9.Joo HS, Kapoor S, Rose DK and Naik VN. The intubating laryngeal mask airway after induction of general anesthesia versus awake fiberoptic intubation in patients with difficult airways. Anesth Analg 2001; 92: 1342-6.  Back to cited text no. 9      
10.Brimacombe J, Keller C, Weidmann K. Limited mouth opening and intubating laryngeal mask (Letter). Can J Anesth 1999; 46: 807.  Back to cited text no. 10  [PUBMED]    
11.Lucas DN, Yentis SM. A comparison of the intubating laryn­geal mask tracheal tube with a standard tracheal tube for fibreoptic intubation. Anaesthesia 2000; 55: 358-61.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Mak PHK, Coi RGB. Submental intubation in a patient with beta-thalassaemia major undergoing elective maxillary and man­dibular osteotomies. Br J Anaesth 2002; 88: 288-91.  Back to cited text no. 12      


    Figures

  [Figure 1], [Figure 2]



 

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