Anesth Analg 2008; 107:1704-1706
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e3181831e2e
NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE
Emergency Airway Management with Fiberoptic Intubation in the Prone Position with a Fixed Flexed Neck
Ming-Hui Hung, MD,
Shou-Zen Fan, MD, PhD,
Chun-Po Lin, MD,
Yen-Chun Hsu, MD,
Po-Yuan Shih, MD, and
Tzong-Shiun Lee, MD
From the Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
Address correspondence and reprint requests to Tzong-Shiun Lee, MD, Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, 7, Chung-San South Road, Taipei, Taiwan. Address e-mail to tslee{at}ntu.edu.tw.
Abstract
We describe emergency airway management with fiberoptic intubation in a patient in the prone position with her neck flexed by a head pin holder during a neurosurgical procedure. Laryngeal mask airway is suggested in emergency difficult airway algorithms; however, this was not feasible in this patient because of her edematous upper airway and limited mouth opening resulting from extreme neck flexion by a head pin holder. The case illustrates the role of fiberoptic intubation in emergency airway management in this critical situation. Maneuvers to facilitate fiberoptic technique are also described.
Accidental tracheal extubation is a life-threatening event during surgery. It is a catastrophic airway crisis, especially in neurosurgical procedures when patients are in the prone position with the neck extremely flexed by the Mayfield head holder. Immediate reestablishment of a clear airway is of great importance for patient survival. A laryngeal mask airway (LMA) is suggested in emergency difficult airway algorithms.1 Case reports in the literature have described emergently inserting a LMA in the prone patient when accidental dislodgement of the endotracheal tube (ETT) has occurred during operation.2–3 However, for cases of fixed flexed neck deformity, insertion of a LMA (or intubating LMA) becomes difficult or even impossible.4–6 We highlight a case of accidental dislodgement of an ETT during operation in this extremely critical position, which was remedied by fiberoptic intubation.
CASE REPORT
A 48-yr-old, 58-kg, woman was scheduled for craniotomy because of a tumor around the third ventricle.
After induction of anesthesia, nasotracheal intubation with a 6.5 cuffed ETT was performed without difficulty under direct laryngoscopy. The position of the ETT was confirmed and well secured over her right nostril at the 26-cm mark. After skull pins were placed, the patient was positioned prone with her neck flexed and laterally rotated to the right side by a Mayfield head holder.
Anesthesia was maintained with air-oxygen-isoflurane ([fraction of inspired oxygen] Fio2: 0.6) and intermittent fentanyl supplement. Seven hours after induction, however, the end-tidal carbon dioxide tracing disappeared suddenly and the ventilator apnea pressure alarm was activated. The ETT was then noted to be dislodged out of the patient’s right nostril. The moisturized breathing circuit was filled with water and the adhesive tapes were wet from nasal and oral secretions. After confirming ETT extubation, the surgical microscope was moved from the operating table and a sterile towel was immediately placed over the patient’s opened dura. The institutional emergency airway algorithm was activated, which included a flexible fiberoptic bronchoscope. Manual ventilation of the lungs was attempted via a facemask. However, this was difficult because upper airway obstruction and the prone position with neck flexed. It was also difficult to depress the chin for introduction of an oropharyngeal airway. After acquisition of a fiberoptic bronchoscope, nasal fiberoptic bronchoscopy (FOB) was attempted with the operator under the operating table, which was difficult and uncomfortable because limited space forced the operator to lie on the floor to perform FOB. Also, the oropharynx was noted to be obstructed by an enlarged tongue. The operating table was then elevated with reverse Trendelenburg position and left-side tilt. The operator then had enough space to perform FOB by sitting on the floor after the table adjustment. Under FOB, the patient’s edematous larynx and vocal cord were visible. After visualizing the carina, the operator advanced the ETT along with the fiberoptic bronchoscope through her right nostril. The tube position was confirmed by direct visualization and capnography. The airway was reestablished in <6 min. During the process of emergency airway management, a continuous high flow of oxygen was given either via facemask or the suction port of the fiberoptic bronchoscope. There was neither arterial desaturation (Spo2 <90%), nor hemodynamic disturbance.
The ETT was firmly secured with adhesive tapes and reinforced by tying the breathing circuit to the Mayfield head holder. The remaining surgery lasted for 3 h. Unfortunately, the patient’s postoperative course was complicated by intraventricular bleeding. She was discharged with a tracheostomy and persistent neurological sequelae.
DISCUSSION
We demonstrated in this case that FOB can be successfully performed to guide the advancement of an ETT into the trachea in this extremely flexed neck position. For ease of FOB performance, the operating table should be elevated to its utmost height with reverse Trendelenburg position and tilt without interfering with the surgical field and opened dura during emergency airway management. The expanded space under the operating table is sufficient for anesthesiologists to perform FOB. The anatomic spatial relationship is comparable to FOB intubation with patients in the sitting position.7
In order to prevent interference with the surgical field and subsequent potential infectious or neurological complications, there are three possible solutions to emergently rescue the airway with patients in the prone position after accidental extubation: 1) LMA (including intubating LMA and subsequent tracheal intubation, using the LMA as a conduit); 2) fiberoptic tracheal intubation, and 3) needle cricothyroidotomy for apneic diffusion oxygenation or transtracheal jet ventilation. Inserting the LMA in the prone position is controversial,8 but emergency airway management in the prone position by a LMA has been demonstrated in previous reports.2–3 We did not use a LMA (or intubating LMA), although it is an early choice in our institutional difficult airway algorithm because of the extremely flexed neck position4–6 and upper airway edema which limited mouth opening. Although the soft tissues of the oropharynx can be displaced in the prone position to facilitate the placement of the LMA,2 the edematous upper airway and limited mouth opening as a result of sustained neck flexion9 could impede the entrance of a LMA. The reasons for difficulty in our patient were thought to be the acute angle between the oral and the pharyngeal axes at the back of the tongue6 and edema secondary to lymphatic and venous congestion after prolonged neck flexion.4,9,10 In our case, we did not see any chance to insert a LMA after failed placement of an oropharyngeal airway. The extremely flexed neck position shortens the sternomental distance (less than two finger breadths) which makes needle cricothyroidotomy unfeasible because of the restricted space. Additionally, the surgeons needed several hours to complete the operation. We feel that a secure airway with FOB ETT intubation, rather than LMA, is the first choice in this critical situation with a patient in the prone position with a fixed flexed neck.
Although we reestablished a clear ETT airway with the guidance of a fiberoptic bronchoscope within 6 min, which is no longer than for airway rescue with a LMA,2 we also had a gurney available if the LMA or FOB failed and the patient desaturated. A gurney is necessary to turn the patient into the lateral or supine position and release him/her from the Mayfield head holder if performing emergent tracheal intubation by direct laryngoscopy, or even emergent cricothyroidotomy. The higher risk of potential infectious or neurological complications, however, should be considered when the dura is open, even when the wound is packed with sterile sponges and/or drapes.
When the patient is to be positioned prone, the anesthesiologist should anticipate and plan for the worst case scenario such as loss of the airway for any reason. Maintenance of oxygenation is of utmost importance to protect the patient from hypoxic injury. Apneic diffusion oxygenation can delay critical arterial desaturation11 and prompt successful emergency airway management, as in our case.
In summary, this case highlights the fact that upper airway obstruction ensues from neck flexion by head pin holder may prevent airway rescue by LMA or mask ventilation. In life-threatening conditions of accidental extubation in the prone position with fixed flexed neck as in our case, emergency airway management with modified techniques of FOB intubation (Fig. 1) is life-saving and important for preventing secondary brain injury during craniotomy.
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Figure 1. Suggested algorithm for emergency airway management in the prone position during craniotomy after accidental extubation (LMA = laryngeal airway mask; FOB = fiberoptic bronchoscopy).
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Footnotes
Accepted for publication April 17, 2008.
Supported by Institutional and/or Departmental Sources.
Attributed to Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine.
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