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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.61 no.4 Campinas July/Aug. 2011
Jayme da Rocha HeckI; Frederico Krieger MartinsII; Maria Teresa Ruiz TsukazanII; Vivian CristofoliII; Maurício PipkinIII; Marner Lopes da SilveiraIII; Jayme de Oliveira RiosIV; José Antônio Lopes de Figueiredo PintoV
IMD, Professor of the Disciplina de Anestesiologia, Chief of the Serviço de Anestesiologia of Hospital São Lucas, PUCRS
IIMD, Resident of the Serviço de Cirurgia Torácica of Hospital São Lucas, PUCRS
IIIMD, Thoracic Surgeon of the Serviço de Cirurgia Torácica of Hospital São Lucas, PUCRS
IVMD, Associate Professor of the Disciplina de Cirurgia Torácica, PUCRS
VMD, Professor of the Disciplina de Cirurgia Torácica, Chief of the Serviço de Cirurgia Torácica of Hospital São Lucas, PUCRS
BACKGROUND AND OBJECTIVE: Difficult airway management in thoracic surgeries is a peculiar subject due to the demands of monopulmonary ventilation with double-lumen tubes. Flexible bronchoscopy guidance is extremely important, but it is not always available. The objective of this report was to describe a case of retrograde selective orotracheal intubation in the absence of specific endoscopy equipment for the procedure.
CASE REPORT: This is a patient with a history of retosigmoidectomy, admitted for a right thoracotomy for a lung lesion. Preoperative anesthetic evaluation did not reveal any clinical and physical exam particularities. After anesthetic induction and ventilation with face mask, two attempts of orotracheal intubation under direct laryngoscopy were ineffective due to difficult visualization of the vocal folds (Cormack-Lehane grade III). Due to the unavailability of specific material for selective endoscopic intubation it was decided to use the retrograde technique using the double-lumen tube. The patient was extubated in the operating room shortly after the end of the surgery without complications secondary to the alternative technique.
CONCLUSIONS: Retrograde selective orotracheal intubation is a minimally invasive technique, low cost, safe, and extremely useful whenever flexible bronchoscopy is not available.
Keywords: Intubation, Intratracheal; Equipment Failure; Airway Management; Thoracotomy.
Difficult airway management is always a delicate situation for the medical team, since failure of planned procedures can cause prolonged hypoxia resulting in severe complications. In thoracic surgery selective orotracheal intubation for monopulmonary ventilation makes this issue even more complex because it demands greater ability of anesthesiologists to handle double-lumen tubes1. Flexible bronchoscopy is an important tool in most cases. However, whenever it is not available the use of alternative procedures is justified2.
The objective of this report was to describe a case in which retrograde orotracheal intubation was used, proven to be effective, inexpensive, and safe. It is considered an important alternative technique.
This is a 51 year-old male who underwent retosigmoidectomy for a malignant neoplasia two years ago who was admitted for surgical approach of an expansive lesion in the inferior lobe of the right lung, most likely metastatic. Pre-anesthetic assessment did not reveal any predictive factor for difficult intubation, neither the past medical history nor the physical exam.
Thiopental (5 mg.kg-1) and cisatracurium (0.20 mg.kg-1) were used for anesthetic induction. The patient was ventilated through a face mask with a mixture of oxygen and isoflurane for 3 minutes, an adequate time to achieve muscular relaxation for tracheal intubation. On direct laryngoscopy the epiglottis remained immobile and superimposed on the glottis hindering visualization of the vocal folds (Cormack-Lehane grade III). Thus, the patient was once more ventilated with a face mask. The second attempt to intubate him was also ineffective. It was then decided to use retrograde orotracheal intubation.
After adequate exposure and asepsis of the cervical region, the cricothyroid membrane was palpated. A mono-lumen central venous puncture kit was used in the tracheal puncture3. A set of needle and syringe with saline 2 mL were used for tracheal puncture. The presence of air bubbles was an indication that the trachea had been punctured. The needle was introduced on a cephalad direction and the metal guide-wire was introduced until it was visualized in the mouth. A pair of hemostatic clamps was used to catch the caudal extremity of the guide-wire close to the cervical region. The cephalad extremity was passed through the left side (bronchial) of a #37 Carlens tube. Tension was applied on both extremities of the guide-wire and the tube was inserted until it stopped, indicating that the distal portion of the tube had reached the site where the guide-wire was introduced into the airways. At this moment, the guide-wire was removed and the procedure continued as a selective intubation4. While advancing the tube it was rotated first at 180º counterclockwise to pass the hook through the vocal folds followed by a 90º clockwise rotation (Figure 1). Interruption of the progression suggested proper positioning of the hook in tracheal carina, which was confirmed both by pulmonary auscultation and capnography, especially if flexible bronchoscopy is not available.
Intercurrences were not observed during surgery. The patient was extubated in the operating room shortly after the end of the procedure. He did not develop complications secondary to the alternative intubation technique used, and he was discharge from hospital on the fourth postoperative day in good clinical conditions.
Ensuring a safe airway is one of the basic rules of anesthesiology. Most often, orotracheal intubation is performed without intercurrences; however, some times one can be faced with difficult airways. Thus, anesthesiologists must be familiar with alternative techniques of orotracheal intubation, since none of them has proven to be superior or effective in all cases. The main techniques used are direct laryngoscopy, retrograde, and guided by flexible bronchoscopy.
Since a consensus on the definition of difficult airway does not exist in literature, in order to unify the language to confront results with greater accuracy the American Society of Anesthesiologists has defined difficult airway as the clinical situation in which a properly trained anesthesiologist has difficulty with face mask ventilation and difficulty in performing tracheal intubation, or both5.
In thoracic surgical approaches, monopulmonary ventilation allows good exposure of the surgical field and less traumatism to the lung parenchyma during manipulation while protecting the dependent lung, justifying the use of selective double-lumen tubes1,6. Thoracotomies in which ipsilateral lung collapse is not achieved result in increased surgical duration and inadequate surgical field. Thus, a difficult airway in thoracic surgery is even more complex. In addition to obtaining a safe airway the anesthetic team has to perform, preferentially, selective intubation to contribute with the surgical team plans. These situations demand experience and adequate training.
In the present study we described a case in which selective retrograde orotracheal intubation was indicated. Despite the wide experience and well-established routines for flexible bronchoscopy for tracheal intubation, specific materials for endoscopic positioning of double-lumen tubes were not available. Thus, after two unsuccessful attempts in ideal conditions by a competent professional a decision for an alternative method was made.
Although very efficient and less invasive, flexible bronchoscopy has some hindrances. Selective endoscopic intubation requires costly materials: a double-lumen tube with a wide lumen made of polyvinyl and flexible bronchoscopy of small caliber. Note that the wear of fiberoptic fibers caused by the trajectory of the tube can damage the device and render it useless7,8. Although widespread, bronchoscopy still is an expensive technology inaccessible to several institutions and health care systems, especially in developing countries. A global survey on the accessibility of flexible bronchoscopy-guided orotracheal intubation on services of thoracic surgery does not exist in the literature. In the institution where the procedure was carried out, a flexible bronchoscope with a small enough caliber to go through a Carlens tube, a rigid tube with a small lumen, was not available and, therefore, it was not appropriate for endoscopy9.
The most common complication related to the retrograde technique is sore throat affecting 60% of patients. Complications of higher clinical importance are rare, and among them we could mention: soft tissue infection, hematoma, hemorrhage, subcutaneous emphysema, pneumomediastinum, and upper airways trauma4,10.
The importance of this report is based on the fact that the management of difficult airway is widely documented in literature; however, material on this situation in the presence of monopulmonary ventilation with double lumen tube especially when access to flexible bronchoscopy is not available is extremely rare.
Thus, retrograde access was more feasible. The procedure was performed without complications demonstrating to be a safe and low cost alternative technique of intubation.
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Correspondence to: Submitted on November 28, 2010. Received from the Serviço de Cirurgia Torácica of Hospital São Lucas. Pontifícia Universidade Católica do Rio Grande do Sul, PUCRS - Porto Alegre (RS) Brazil.
Dr. Frederico Krieger Martins
Rua José Sanguinetti, 130 Ipanema
91760490 - Porto Alegre, RS, Brazil
Approved on January 31, 2011.
Submitted on November 28, 2010.
Received from the Serviço de Cirurgia Torácica of Hospital São Lucas. Pontifícia Universidade Católica do Rio Grande do Sul, PUCRS - Porto Alegre (RS) Brazil.