Anesth Analg 1999;88:467
© 1999 International Anesthesia Research Society
LETTERS TO THE EDITOR
Airway Adjunct to an Unanticipated Difficult Airway
Jacinta McGinley, FFARCSI, and
John McAdoo, FFARCSI
Department of Anaesthesia Cork University Hospital Cork, Ireland
A 29-yr-old woman attended our hospital for an elective laparoscopy. On examination, she was described as ASA physical status I, Mallampati grade II (1), and she had a small mouth (Figure 1). After the induction of anesthesia with propofol and fentanyl, muscle relaxation was provided with atracurium. Hand ventilation via a size 4 face mask was easily managed. Laryngoscopy was possible, but it was not possible to visualize the epiglottis and vocal cords. After maneuvering the patient's head, a further attempt at endotracheal intubation was unsuccessful. The fiberoptic laryngoscope was prepared, and attempts at inserting the Ovassapian (2) and the Williams and Harrison (3) airways to facilitate fiberoptic endotracheal intubation were made. However, because of the patient's small mouth, it was not possible to pass either of these airways. The nasal route was not used, as it had not been prepared. We then decided to use a Guedel airway that had previously been modified by one of the consultant anesthetists in our department. This Guedel airway (size 3) had its center colored mould area removed and was cut along its entire length the width (1.8 cm) of the colored mould portion with a Stanley knife blade to facilitate the central open space (Figure 2). The airway was then filed to ensure that there were no sharp edges and sterilized before use. The airway angles the fiberoptic scope so that it is useful for visualizing an anterior larynx and allows easy orientation of the fiberoptic scope in such patients. The airway could be disengaged from the fiberoptic laryngoscope and endotracheal tube. This airway was sufficiently narrow to pass into the mouth of this patient yet still facilitate the fiberoptic laryngoscope. A size 7.0 endotracheal tube was successfully passed without any trauma to the airway.
This case also highlights some of the airway problems that can occur in patients who have small mouths or a limited mouth opening. Our modification of a Guedel airway is yet another simply made device that can change an apparently difficult intubation into a manageable one. We would advise the addition of this simple airway adjunct to each difficult intubation trolley.
References
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Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth 1985;32:429–34.
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Ovassapian A. A new fiberoptic intubating airway. Anesth Analg 1987;66:S132.
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Williams RT, Harrison RE. Prone tracheal intubation simplified using an airway intubator. Anaesth Soc J 1981;28:288.
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