|Year : 2021 | Volume
| Issue : 1 | Page : 91-93
Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation
Nisha Rajmohan1, Felix Nelson2, Surjaya Upadhyay3
1 Department of Anaesthesia and Critical Care, Astermedcity, Kuttisahib Road Cheranalloor South Chitoor, Kochi, Kerala, India
2 Department of Anesthesia and Critical Care, PVS Memorial Hospital, Kaloor, Kochi, Kerala, India
3 Department of Anaesthesia and Critical Care, NMC Royal Hospital, DIP, Dubai Investment Park, Dubai, UAE
|Date of Submission||20-Oct-2019|
|Date of Decision||25-Feb-2020|
|Date of Acceptance||30-Apr-2020|
|Date of Web Publication||22-Jan-2021|
Department of Anesthesia and Critical Care, Aster Medcity, Kuttisahib Road Cheranalloor, South Chittoor, Kochi - 682 027, Kerala
Source of Support: None, Conflict of Interest: None
Difficult airway still is one of the dreaded crises in anesthesia. A well-formulated plan with all the necessary equipment should be ready when such situations are anticipated, but unanticipated difficulties can arise, and managing such cases is a nightmare for the anesthesiologist. Most hospitals in the developing countries are not equipped technically with all the modern equipment and gadgets as far as anesthesia is concerned. In a resource-constrained area, the skill and innovative ideas of the anesthesiologist often emerge as an alternative option in dealing with such cases. Here, we describe two cases of difficult intubation by conventional approach, which were managed successfully using a pediatric gastroscope and a flexible cystoscope as an alternative to fiberoptic bronchoscope.
Keywords: Airway management, difficult airway, fiberoptic bronchoscope, flexible cystoscopy, gastroscope, intubation
|How to cite this article:|
Rajmohan N, Nelson F, Upadhyay S. Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation. Med J DY Patil Vidyapeeth 2021;14:91-3
|How to cite this URL:|
Rajmohan N, Nelson F, Upadhyay S. Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Mar 9];14:91-3. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/91/307674
| Introduction|| |
Fiberoptic bronchoscope (FOB) and video laryngoscope-assisted intubation are ideal to manage anticipated difficult airway in most situations. These equipments are not a part of difficult airway cart as they are too expensive., In such situations, airway management options for difficult intubation are limited to blind nasal intubation, intubation through the supraglottic airway, retrograde intubation, or surgical airway. Pediatric gastroscope and flexible cystoscope though designed for gastroscopy and cystoscopy, respectively, can be an alternative in dealing with difficult to intubate scenarios in adults. We encountered two cases of failed direct laryngoscopic intubation, which were successfully managed using a pediatric gastroscope and a flexible cystoscope.
| Case Report|| |
A 50-year-old male, weighing 72 kg, was posted for laparoscopic cholecystectomy under general anesthesia. Apart from well-controlled diabetes mellitus on oral hypoglycemics and long-standing ankylosing spondylitis, he did not have any other significant medical problem. Airway examination revealed severely restricted neck movement in flexion and extension, mouth opening was adequate with Mallampatti Class II. Difficult intubation was expected, and the patient was counseled about the possibility of awake intubation under airway blocks and topical anesthesia. They were also given the option of referral to a higher center which the patient refused. Written and informed consent was obtained for the anesthesia. Difficult airway cart with supraglottic devices, stylet, and bougie was kept ready. In the absence of proper FOB, the suggestion was made on the use of a pediatric gastroscope as an alternative. After a discussion with gastroenterologist, it was decided to give a trial with a pediatric gastroscope for awake nasal intubation. Intravenous access was established, and glycopyrrolate 0.2 mg was given, and oxymetazoline drops were used as a nasal decongestant. The patient was asked to apply 2% lignocaine jelly intranasally and transtracheal block was given with 4 ml 4% lignocaine. A pediatric gastroscope (GIFXP160: outer diameter − 5.9 mm, channel diameter − 2 mm, and length − 100 cm) was used for intubation. An endotracheal tube (ETT) size 8.0 mm was railroaded over the pediatric gastroscopes and was introduced under videoscope guidance [Figure 1]. As anesthesiologists are not trained in the use of gastroscope, we took the help of a gastroenterologist who successfully introduced gastroscope into the trachea, and subsequently, the ETT was threaded over it [Figure 2]. Once the placement of ETT was confirmed by capnograph, the patient was induced with propofol 100 mg with fentanyl 100 μg and paralyzed with atracurium 40 mg. Laparoscopic cholecystectomy was completed in 1 h uneventfully, and the patient was extubated when fully awake.
A 56-year-old female patient, weighing 64 kg, was posted for laparoscopic low anterior resection for carcinoma rectum. She had no history of any other medical comorbidity. Airway assessment revealed adequate mouth opening with Mallampatti Class III with a full range of neck movements. We planned a conventional induction and direct laryngoscopic intubation of the trachea. The patient was induced with propofol 150 mg, fentanyl 100μg, and atracurium was given after ensuring adequate mask ventilation. Three attempts at intubation by two experienced anesthesiologists using two different types of laryngoscopes blades (Macintosh and McCoy) with stylet, as well as a bougie, failed. The patient was ventilated intermittently through the mask in between the attempts and did not desaturate at any point in time. Our options available were either to awaken the patient or to use a gastroscope for assistance.
Unfortunately, the pediatric gastroscope was in use in the endoscopy suite and hence unavailable. Second-generation laryngeal mask airway is an acceptable technique for laparoscopic surgeries. Since it was difficult intubation and a prolonged surgery, we preferred a definitive airway that is an ETT.
The only other available endoscope was the flexible cystoscope with an outer diameter of 4 mm and an inner diameter of 1.7 mm. An ETT of 7.5 mm was threaded over the cystoscope after cutting the tube to a length of 24 cm, as the length of the cystoscope is only 30cm. A suction catheter was introduced along the side of the cystoscope by an assistant, as the option for suction is not available on this scope, which was introduced under videoscopic assistance, and the patient was intubated successfully [Figure 3].
|Figure 3: Cystoscope.guided orotracheal intubation after cutting the tube to 24 cm mark and threading it over the cystoscope|
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| Discussion|| |
In a true sense, a difficult airway cart is incomplete without a dedicated FOB. Despite the importance of this tool, it has not been included in many centers, even at the tertiary level, for reasons of cost, inadequate expertise, and freelancing practice. In such locations, the management of difficult airway is extremely challenging and often leads to alternative and innovative techniques of intubation.
Since the working principle of gastroscope, cystoscope, and flexible FOB are the same, an anesthetist trained in FOB will be able to guide a gastroscope. However, the length of the gastroscope requires an assistant to hold the scope. Since it was our first attempt, we received help from our gastroenterologist. Our literature search revealed that the gastroscope-assisted intubation had been reported before., Compared to the FOB, the gastroscope offers a number of additional advantages such as a larger screen and better tip control, as it can allow movement in multiple directions and better suctioning. The tip of the gastroscope can also be cleaned well when the field is flooded with blood and secretions. Pediatric gastroscopes can only accommodate ETT's above 7.5 mm, while adult endoscopes are too large. ETT size 7.5 mm was snugly fitting around the gastroscope and was not smoothly sliding over the scope. Hence, we decided to go ahead with an 8.0 mm ETT. In case, there was a difficulty in nasal intubation, we had plans to intubate orally. The pediatric gastroscope can be used for both nasal and oral intubation. A bite block is used to prevent damage to the scope when used for oral intubation. We used 8.0 mm ETT through the nasal route. We found suction and visualization to be better with the gastroscope. Gastroscopes are longer than the FOB, and therefore, assistance is required to hold the scope for the proper control of the movements. We were unable to find any reference regarding the use of flexible cystoscopes for intubation. Practice with gastroscope-assisted intubation gave us the courage and confidence to go ahead with the cystoscope-assisted intubation. Other shorter flexible fiberoptic endoscopes such as nasopharygoscopes and ureteroscopes are too short to be considered for endotracheal intubation. The use of a guidewire with a tube exchanger has been advocated. A similar wire technique for a typical length adult endoscope allowed the use of pediatric ETTs. The short length of the cystoscope presented a problem to us, but we overcame it by cutting the tube to 24 cm and threading it over the scope. One major drawback with a flexible cystoscope was the absence of an inbuilt suction port, though supplemental high flow oxygen delivered through the working port of cystoscope may have helped to a certain extent to clear secretions by blowing it away from the tip. We used a separate suction catheter under direct laryngoscopy to clear the pharyngeal secretions. The flexible cystoscope is similar to a pediatric gastroscope in diameter and can accommodate ETT with an internal diameter >7.0 mm. The idea of reporting these cases is to share our experience on the use of other possible alternative devices for intubation. These devices can also be lifesaving in the management of the airway.
| Conclusion|| |
Difficult intubation can occur unexpectedly. It is important to think “out of the box” and use the resources available to us in an innovative way. However, the use of alternatives devices should be an exception than a rule.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]