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GENERAL ARTICLES

Radiologic-Assisted Endotracheal Intubation

Charles E. Reier, MD^*, and Allan R. Reier, MD

*Department of Anesthesia, Jay County Hospital, St. Vincent Randolph Hospital, Winchester, Indiana; and Department of Interventional Radiology, Washington University Medical Center, St. Louis, Missouri

Address correspondence and reprint requests to Charles E. Reier, MD, 520 Wildrose Drive, Greenville, OH 45331. Address e-mail to rreier{at}hotmail.com

	Abstract

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We accomplished endotracheal intubation by using fluoroscopic direction in a patient presenting a difficult airway both on the basis of a preanesthetic physical examination and on the basis of a potential for cervical cord injury associated with complicated laryngoscopy. Under topical anesthesia, a multipurpose angiographic (MPA) catheter over a Bentson wire was advanced into the trachea under intermittent C-arm fluoroscopic guidance while the occiput, cervical spine, and mandible remained in a neutral position. The endotracheal tube was then easily advanced over the MPA catheter into the trachea, where the location was documented by fluoroscopic view. Because of judicious use of topical anesthesia and the small diameter and flexibility of the MPA catheter, the unsedated patient remained comfortable throughout the procedure. The stored data were later transferred to a compact disk, and a copy was provided to the patient as an adjunct to Medic-Alert. Unlike fiberoscopy, with which the view can be totally obscured by secretions, blood, and abnormal anatomy, the direction and location of the MPA catheter within the airway were easily identifiable throughout the procedure. The small diameter of the MPA (1.5-mm outer diameter) should allow placement of endotracheal tubes as small as 3.0-mm inner diameter—an option not available even with pediatric instruments. Although time was not a consideration, the procedure was accomplished in <12 min with 22 s of fluoroscopy. We believe that with experience, atraumatic intubation of a difficult airway could be accomplished routinely in less than 2 min with radiological-assisted intubation.

IMPLICATIONS: Radiologic-assisted intubation facilitated endotracheal intubation without sedation, instrumentation, or significant movement of the occiput, cervical spine, or mandible. The procedure was accomplished in <12 min and with only 22 s of fluoroscopy. This approach provides the ultimate adjunct to the preoperative airway physical evaluation while providing for immediate (or delayed) atraumatic endotracheal intubation. The diagnostic information and procedure can be recorded on a compact disk.

	Introduction

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Most current approaches to intubation rely on refinements of a century-old technology, and fiberoptic approaches to airway management are often precluded for technical reasons (1). A current report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway (2) indicates that the issue remains problematic, even after a decade of focused effort.

Although it recognized minor progress, the task force failed to address the most serious evolving issue regarding the management of the difficult airway, i.e., the fact that five paths of the difficult airway management algorithm end with "invasive airway access" (tracheotomy or cricothyrotomy) or "call for help." There is reason to believe that the number of physicians trained and willing to perform these procedures in emergencies is dwindling in large teaching institutions and unavailable in most other venues. The gravity of this issue is highlighted by reports ranging from lawsuits¹ and complications of percutaneous tracheostomy² (3) to the tremendous variation across emergency medicine residency programs regarding the availability of devices for difficult airway management. Only half of the directors of these programs had any experience with common difficult airway devices (4).

These observations force the authors to conclude that our ability to manage difficult and emergent airways could be regressing and that a dramatic new approach is required. The purpose of this report is to describe the results and rationale of radiologic-assisted intubation (RAI).

	Case Report

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A 68-yr-old, 90-kg, 177.8-cm man was scheduled for repair of an extensive ventral hernia under general anesthesia. Regional anesthesia was problematic because the patient had significant lumbosacral spine deformities coupled with segmental sensory deficits that affected both extremities. Continued reports of transient and permanent neurological symptoms associated with both subarachnoid and epidural anesthesia made the choice of regional anesthesia unacceptable to the patient. Unfortunately, general anesthesia with direct laryngoscopy and intubation presented an even greater concern because of severe cervical spine pathology, again combined with marked peripheral sensory deficits. The patient’s previous roentgenographic examination revealed mild compression fractures of C5 and C6, and cervical magnetic resonance imaging revealed hard and soft disk lateral herniation, central disk herniation, and bilateral neural foramina narrowing that involved C3 through C6. On the basis of his history and physical examination, it was impossible to determine whether the neurological deficits were static or progressive.

The possibility that direct laryngoscopy, especially if complicated, could cause or be coincident with neurological deterioration appeared real. In concert with an interventional radiology consult, a decision was made to use fluoroscopic-assisted intubation without laryngoscopy in an attempt to eliminate this risk.

With the patient supine, topical benzocaine 14%/butamben 2%/tetracaine HCl (Cetacaine®) 0.5-s spray was applied to the posterior pharynx. After an oral airway was placed, a multipurpose angiographic (MPA) catheter (6F) over a Bentson wire (0.89-mm diameter; 150-cm length) was advanced to the hypopharynx with a Siemens C-arm Model 313 5600. With manipulation of the Bentson wire/MPA, the true cords were reached (Fig. 1). The Bentson guidewire was advanced through the catheter to the level of the cords (Fig. 2). The MPA catheter was advanced into the trachea. After the oral airway was removed, a Mallinckrodt 6.0-mm inner diameter endotracheal tube was advanced over the MPA catheter to the epiglottic area, and an additional topical benzocaine 14%/butamben 2%/tetracaine HCl (Cetacaine®) 0.5-s spray was given via the endotracheal tube on inhalation. After approximately 60 s, the endotracheal tube was advanced over the MPA catheter into the trachea (Fig. 3) to 22 cm, where the tube was taped without reaction. The MPA catheter was removed and the endotracheal tube placement confirmed. The total procedure time was 12 min with a total fluoroscopic exposure of 22 s.

View larger version (88K): [in this window] [in a new window]   Figure 1. Lateral view shows a multipurpose angiographic (MPA) catheter tip directed anteriorly above the level of the cords.

View larger version (82K): [in this window] [in a new window]   Figure 2. Lateral view shows a Bentson wire advanced through a multipurpose angiographic (MPA) catheter to the level of the vocal cords.

View larger version (81K): [in this window] [in a new window]   Figure 3. Lateral view shows the endotracheal tube advanced into the trachea over the multipurpose angiographic (MPA) catheter.

	Discussion

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Although there are techniques available for the management of the patient whose airway presents difficult features on the basis of the preoperative airway physical examination (PAPE), experienced investigators report significant failure rates with all techniques for intubation (2). Fiberoptic tracheal intubation carries significant complication and failure rates based on subtle differences in technique, equipment, and expertise. Furthermore, elements of support for the anesthesiologist managing a difficult airway, such as fiberoptics, retrograde intubation, and invasive airway instruments, are often unavailable in rural and ambulatory facilities. By contrast, C-arm fluoroscopy is becoming universally available, making RAI possible in most all facilities.

Unlike other techniques available, RAI provides the ultimate in diagnostic information while being atraumatic, quick, and efficient. The procedure does not require opening the mouth (beyond 1 cm), positioning the head, or moving the cervical spine and can be easily accomplished without sedation. On the basis of existing technology, a compact disk of the patient’s anatomy, the procedure, and successful endotracheal intubation can be provided. This information can subsequently be viewed in the operating room, intensive care units, and so on as a guide to future airway management. Information stored in this format can be extremely useful in the patient with grossly abnormal airway anatomy due to congenital or acquired diseases such as Down’s and Turner’s syndromes, rheumatoid arthritis, ankylosing spondylosis, pharyngeal tumor, and trauma. This visual information totally eclipses that obtained from the PAPE in the way that a fluoroscopic view of the chest excels over percussion and auscultation.

We believe that RAI offers a definitive and superior approach to the difficult airway and, if considered prospectively, could reduce the need for cricothyrotomy/tracheostomy. Unfortunately, not all difficult airways are identifiable by PAPE; thus, fluoroscopic assistance and RAI should be considered as a useful adjunct whenever serious airway deterioration occurs, i.e., before or during the "call for help," can’t intubate/can’t ventilate, or surgical airway portions of the ASA difficult airway algorithm.

	Acknowledgments

 
We thank Med-Econ, Inc., for document preparation.

	Footnotes

 
¹ Case Archive. Hospital Administration, Anesthesiology, Otolaryngology. MedQuest Ref. 599201; Alexander vs Rush North Shore Medical Center Fulford vs Selly Oak Hospital; Birmingham, England.

² Bliznikas D. Percutaneous tracheostomy. eMedicine. February 11, 2003.

	References

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2. Practice guidelines for management of the difficult airway. Anesthesiology 2003; 98: 1269–77.[Web of Science][Medline]
3. Kedjanyi WKA, Gupta D. Near total transaction of the trachea following percutaneous dilatational tracheostomy. J R Coll Surg Edinb 2001; 46: 242–3.[Medline]
4. Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: results of a national survey. Ann Emerg Med 1999; 33: 694–8.[Medline]
5. Muckart DJJ, Bhagwarjee S, van der Merwe R. Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures. Anesthesiology 1997; 87: 418–20.[Web of Science][Medline]
6. Kihara S, Brimacombe J, Taguchi N, et al. Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery. Anesth Analg 2000; 91: 195–200.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Reier, C. E. Articles by Reier, A. R. Search for Related Content PubMed PubMed Citation Articles by Reier, C. E. Articles by Reier, A. R. Related Collections Airway Equipment