|Year : 2008 | Volume
| Issue : 1 | Page : 87
Difficult Airway Management in A Case of Thalassaemia Major
Neerja Bharti1, Jagan Devrajan2
1 Assistant Professor, Department of Anesthesia, PGIMER, Chandigarh., India
2 Senior Resident, Department of Anesthesia, AIIMS, New Delhi., India
|Date of Acceptance||10-Dec-2007|
|Date of Web Publication||19-Mar-2010|
Assistant professor, Department of Anaesthesiology and intensive care, PGIMER,Chandigarh-160012
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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  . 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  .
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|| |
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|| |
Fibreoptic guided tracheal intubation is accepted as the gold standard in cases of suspected difficult intubation , . However, upto 13% failure rate has been reported in literature  , 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  . Repositioning of tube is helpful but does not always improve the chances of success or may cause trauma to laryngeal structures  . 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  . There are case reports where failed fibreoptic intubation was successfully managed with ILMA guided intubation  . 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  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  .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  .
Submental intubation was reported  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.
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[Figure 1], [Figure 2]