Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report
A 28-year-old male patient diagnosed with occipito-atlanto-axial instability was scheduled for a cervical fusion. He was 76 kg, 169 cm, Mallampati class III, with a thyromental distance of 7.5 cm and limited head and neck mobility. He was intubated with a fiberoptic bronchoscope (Olympus LF-GP, Olympus Optical Co., Tokyo, Japan) in an awake state, and general anesthesia was maintained with sevoflurane. The operation was performed via the posterior approach in the prone position. Total operation time was about 6 hours, and there were no significant intraoperative events. During emergence, after confirming his stable condition (clear consciousness, adequate weaning profile), he was extubated in the operating room and sent to the intensive care unit. However, immediate O2 desaturation with dyspnea was noted. After giving the patient 5 mg of midazolam for sedation, reintubation with a laryngoscope was attempted twice but failed due to the short jaw-chest distance, neck rigidity, and the flexed cervical angle after cervical spine fixation. His Cormack and Lehane grade was 4. The laryngoscopic view did not improve, even with adequate repositioning of the head (BURP maneuver: backward, upward, and right lateral displacement of the thyroid cartilage). Oxygen supply was continuously provided through a face mask to maintain O2 saturation above 90%. Nasotracheal intubation with a fiberoptic bronchoscope was attempted but also failed due to severe swelling of the tongue, epiglottis, retropharyngeal soft tissue, and the upper airway. Another interfering factor was the bloody secretions in the oropharynx, which obscured the tip of the fiberoptic bronchoscope. As oxygen saturation was able to be maintained at 90% using bag-valve-mask ventilation and the patient was not at increased risk of aspiration of gastric contents, we decided to perform tracheal intubation via an appropriately sized laryngeal mask airway (LMA). Because there was no intubating laryngeal mask airway (ILMA) available in our facility, we used a proseal LMA as an alternative. A #4 LMA was easily inserted and functioned properly. We passed a 5.0 mm endotracheal tube (ETT, without a balloon) through the LMA with the aid of a fiberoptic bronchoscope into the trachea. We then passed a tube exchanger with an outer diameter 3.7 mm (Cook Critical Care, Bloomington, Indiana, USA) through the 5.0 mm ETT in order to exchange the 5.0 mm ETT and LMA with a 7.5 mm ETT (). After successfully securing the airway, the patient was sedated with continuous infusion of midazolam and was mechanically ventilated overnight. The next day, extubation was carefully carried out by the anesthesiologist after examining cervical lateral radiographs for any signs of soft tissue edema. No further airway complications developed.