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LETTER TO THE EDITOR

Continuous Anesthetic Insufflation and Topical Anesthesia of the Airway Using Trachlight in Chronic Facial Burns

Department of Anesthesiology, J.N. Medical College, A.M.U., Aligarh, India, Seeras_alig{at}rediffmail.com

To the Editor:

In chronic burn patients undergoing reconstructive surgery, securing a patient airway quickly, atraumatically, and, preferably, on the first attempt is a challenge. We describe a patient of chronic severe burns in whom fiberoptic endotracheal intubation failed but in whom a modified Trachlight intubation enabled us to secure the airway uneventfully.

An ASA physical status III 35-yr-old man with history of epileptic convulsions presented with severe burns of the head, neck, and chest sustained 7 mo previously (Fig. 1). The patient was scheduled for transfer of pedicle flap to the forehead.

View larger version (139K): [in this window] [in a new window]   Figure 1. Modified Trachlight intubation in progress. A: Syringe with local anesthetic, B: Trachlight in the process of placement, C: Infant feeding tube attached to continuous anesthetic insufflation line.

The patient had a mouth opening of 1.0 cm and neck extension was restricted because of two bands of anterior neck contracture. There was complete destruction of both the eyes and external nose. The turbinates and nasal passages had granulation tissue. All other relevant investigations were within normal limits.

The patient refused an awake tracheal intubation. Anesthesia was induced with halothane in 100% oxygen. Fiberoptic intubation was attempted after topical nasal application of ephedrine 0.75% but failed as a result of bleeding. A size 5F infant feeding tube was attached beginning from the tip of the Trachlight to the wand.

The Trachlight-endotracheal tube assembly was now configured into a "C-shape" against the patient's lateral facial profile (Fig. 1). The tip of the wand was placed at the thyroid cartilage; the next bend was taken at the level of the posterior one third of the mandible such that the other end of the C portion of the wand was approximately at the level of the external nasal opening. The Trachlight with infant feeding tube in a 7.0 mm inner diameter endotracheal tube was now introduced and maneuvered so as to make the glow of light appear in the midline just below the scar. At this juncture 1 mL of 2% lidocaine was injected with moderate force via the infant feeding tube. After waiting for 60 s, the Trachlight glow was gradually moved into the larynx (Fig. 2). Minimal coughing and bucking were noted, and a second 1 mL of 2% lidocaine was injected through the infant feeding tube. The stylet was partially withdrawn and Trachlight-endotracheal tube assembly was taken until the light glow just disappeared under the suprasternal notch. The clamp was released, the Trachlight disengaged and removed, and correct endotracheal tube placemen was confirmed. During this period, the patient continued to receive 4 L of oxygen and 2% halothane via the infant feeding tube (Fig. 2) except for two brief periods when lidocaine was injected through the infant feeding tube. The entire procedure lasted 11 min. Oxygen saturation remained between 97% and 99%.

View larger version (145K): [in this window] [in a new window]   Figure 2. Trachlight endotracheal tube assembly in the trachea with a well circumscribed glow in the front of the neck. A: Continuous anesthetic insufflation through infant feeding tube, B: Well circumscribed light glow, C: Trachlight-endotracheal tube assembly.

Tracheostomy was avoided, as it would result in loss of speech in an illiterate and visually handicapped patient. We therefore opted for Trachlight-aided intubation with an attached size 5F infant feeding tube on the side of the wand. This gave us the flexibility of using this additional tubing for continuous insufflation of oxygen and halothane during a procedure tending to be prolonged. This also gave us the option of injecting lidocaine on the glottic and intratracheal structures to obtund coughing and bucking on the tracheal tube.

In conclusion, using an infant feeding tube with Trachlight-endotracheal tube assembly serves the triple function of assisting intubation, maintaining inhalational anesthesia, and administering topical local anesthetic.

This article has been cited by other articles:

				R. Sharma, R. Kumar, S. Kumar, and N. R. Gupta Connector Assembly to Improve Performance of the Lighted Stylet (TrachlightTM) for Nasotracheal Intubation Anesth. Analg., December 1, 2008; 107(6): 2095 - 2096. [Full Text] [PDF]

				F. S. Xue, Q. Y. Yang, and X. Liao Topical anaesthesia of the airway using TrachlightTM and MADgic(R) atomizer in patients with predicted difficult tracheal intubation Br. J. Anaesth., December 1, 2007; 99(6): 920 - 921. [Full Text] [PDF]

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