Department of Anesthesiology, Johannes Gutenberg-University, Langenbeckstraße 1, Mainz 55131, Germany
* Corresponding author. E-mail: Tim.Piepho{at}gmx.de
Accepted for publication March 18, 2005.
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Abstract |
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Keywords: airway ; equipment, tubes, tracheal ; ventilation, failure
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Introduction |
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Case report |
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After 4 min of breathing 100% oxygen via facemask, anaesthesia was induced with fentanyl 0.15 mg and thiopental 450 mg. Because ventilation via a facemask was easy to accomplish, atracurium 45 mg was administered to facilitate laryngoscopy. Following a 3-min period of mask ventilation, a 7.0-mm cuffed nasotracheal tube was inserted into the patient's right nostril. No force had to be applied to advance the tip of the tube into the hypopharynx.
Bleeding from the nasopharyngeal region was noticed during laryngoscopy using a Macintosh blade 4. Visualizing the epiglottis was impossible, corresponding to a CormackLehane grade 4 airway.8 Following the institutional emergency airway algorithm,9 the nasal tube was removed and the lungs were ventilated using a facemask. At this time, ventilation became difficult and it was only possible to achieve tidal volumes <300 ml.
A straight Henderson blade was used in a second attempt to direct laryngoscopy. Despite suctioning and applying backward upward rightward pressure (BURP) to the larynx,10 the epiglottis could not be visualized. Another attempt using a laryngoscope to elevate the base of the tongue in conjunction with a rigid Bonfils fibrescope also had to be abandoned. The progressive bleeding prevented the use of any fibreoptic technique. Another attempt was made using a size 5 intubating laryngeal mask airway, but sufficient ventilation could not be achieved. Because the intermittent mask ventilation became progressively inadequate, an interdisciplinary decision was made to control the airway by cricothyroidotomy.
Upon completion of cricothyroidotomy, ventilation and oxygenation improved significantly, with arterial oxygen saturation increasing from 52% to 95% within 60 s. The bleeding was stopped by tamponade of both turbinates; fibreoptic bronchoscopy was performed to remove any aspirated blood.
No further complications occurred, and the patient was transferred in a stable condition to an intensive care unit. Extubation was performed without complications 24 h after the event and the patient did not suffer from any sequelae.
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Discussion |
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The sequence of actions performed in this patient, i.e. prelaryngoscopy manoeuvres including insertion of the nasotracheal tube, laryngoscopy, and endotracheal intubation, is generally accepted.1 The present case illustrates that complications caused by the nasal passage of the tube in conjunction with unanticipated airway difficulties may severely endanger the patient. Blood in the airways can produce a dramatic deterioration in conditions by obscuring the view during laryngoscopy and by aspiration of blood into lungs. If fiberoptic intubation is considered, blood and secretions may obscure the view.14
The potential danger of causing bleeding by passing the tube through the nares in a patient with unanticipated airway difficulties can easily be avoided. After induction of anaesthesia, facemask ventilation and muscle relaxation, an attempt should be made to estimate any potential problems in visualizing airway by direct laryngoscopy using the CormackLehane classification. The tube should then be passed through the nose only in patients with a grade 1 or 2 view (Fig. 1). This new sequence of actions leaves an option for alternative techniques. If laryngoscopy is difficult, fibreoptic or supraglottic techniques can be used without bloody secretions in the hypopharynx. On the other hand, if direct laryngoscopy can be performed but the passage of the tube causes bleeding, the trachea can be intubated rapidly using either the nasal or the oral route.
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References |
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2 Moore DC. Middle turbinectomy: a complication of IMPROPER nasal intubation? Anesthesiology 2000; 92: 15045
3 Williams AR, Burt N, Warren T. Accidental middle turbinectomy: a complication of nasal intubation. Anesthesiology 1999; 90: 17824[CrossRef][ISI][Medline]
4 Watanabe S, Yaguchi Y, Suga A, Asakura N. A bubble-tip (Airguide®) tracheal tube systemits effects on incidence of epistaxis and ease of tube advancement in the subglottic region during nasotracheal intubation. Anesth Analg 1994; 78: 11403[Abstract]
5 Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000; 91: 698701
6 Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 14: 1727
7 Latorre F, Otter W, Kleemann PP, Dick W, Jage J. Cocaine or phenylephrine/lignocaine for nasal fibreoptic intubation? Eur J Anaesthesiol 1996; 13: 57781[CrossRef][ISI][Medline]
8 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 110511[ISI][Medline]
9 Thierbach AR. Advanced prehospital airway management techniques. Eur J Emerg Med 2002; 9: 298302[Medline]
10 Takahata O, Kubota M, Mamiya K, et al. The efficacy of the BURP maneuver during a difficult laryngoscopy. Anesth Analg 1997; 84: 41921[Abstract]
11 Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med 1981; 10: 1424[ISI][Medline]
12 Enk D, Palmes AM, Van Aken H, Westphal M. Nasotracheal intubation: a simple and effective technique to reduce nasopharyngeal trauma and tube contamination. Anesth Analg 2002; 95: 14326
13 Smith JE, Reid AP. Identifying the more patent nostril before nasotracheal intubation. Anaesthesia 2001; 56: 25862[CrossRef][ISI][Medline]
14 Coe TR, Human M. The peri-operative complications of nasal intubation: a comparison of nostril side. Anaesthesia 2001; 56: 44750[CrossRef][ISI][Medline]