The new ASA guidelines for the management of the difficult airway indicate the use of video laryngoscopy with an IA level of evidence because many studies show that with them, a high incidence of successful OTI is achieved on the first attempt, without a higher rate of injuries in the airway derived from its use being associated. The handling of these devices is currently being extended, being used in recent years as a useful tool for OTI in awake patients.
The paralysis of the recurrent laryngeal nerves is a relatively frequent pathological condition if the close relationship of the nerves with a series of mediastinal structures is taken into account. The recurrent latrogenic injury caused after cardiac surgery ranges from 0.5 – 2%. When a bilateral paralysis of the vocal chords occurs, they are in a position of adduction, which constitutes a medical emergency upon causing a significant obstruction of the airway.
A patient of 66 years who was involved on a scheduled basis for aortic valve replacement and pulmonary lung ablation. After six days of uneventful postoperative care, the patient was discharged. For proper control of acute pain, the patient required the placement of two perforated catheters for continuous Temena POLYCATH infiltration located in the steronomy (one in the subfascial plane above the sternum and the second one in the subcutaneous tissue above the fascia) with a 0.25% levobupivacaine infusion rate of 5 ml / h by elastomeric pump. The catheters were removed without showing any adverse effects or complications during the period of administration. As the only clinical data, a recurrent paralysis that was assessed by ORL was evident, raising its evolutionary track under conservative treatment.
He went to Accident and Emergency after two months presenting dysphagia, stridor and dysphonia, assuming a worsening of the clinical picture of recurrent paralysis. With the help of the bronchoscope, the left vocal chord was immobilised with very discreet movement of the right vocal chord. Given the likely total obstruction of the airway, an urgent surgical tracheotomy was proposed. It was decided to perform awake OTI with Airtraq. The patient was informed and consented. After the basic monitoring of the patint, premedication with 3mg midazolam and 0.8mg atropine began. The preparation of the airway was performed by continuous nebulisation with 4% lidocaine for 15 minutes with instillation of several puffs in lingual mucous and pharyngeal pillars. After that, we proceeded to sedation with remifentanil with good cooperation from the patient.
The Airtraq and the visualisation of the glottis and the vocal chords was introduced, we confirm the paramedian position of the chords and their lack of mobility when the patient is asked to take a deep breath. We irrigated the transglottal surface with 4% lidocaine through the MADgic atomiserthat we inserted at the side of the device. After a few seconds, intubation was achieved at the first attempt without any resistance by maintaining oxygen saturation above 97% at all times. The tracheotomy was performed without incident
In our case, we decided to use this device with the patient awake because it offered the added advantage of visualising the glottis when passing the endotracheal tube through the injured chords and thus minimising the injury thereof.
Performing the tracheotomy under local anaesthesia and sedation could be an alternative in terms of the anaesthetic technique employed, but given our experience and according to otolaryngologists, we considered that performing the surgical procedure with the patient previously intubated and under general anaesthesia, could result in lower morbidity and increased safety for the patient.
We believe that the combination of sedation with remifentanil and local anaesthesia of the airway was necessary in order to obtain an acceptable degree of patient comfort and it allowed us to evaluate and manipulate the airway without resistance from the patient, as well as diagnosis and documentation of the clinical case. On the other hand, the use of continuous local anaesthetic infusion catheters through Omnibus Accufuser elastomer 05050730L by Grifols in surgical wounds has not been directly linked in any way with the event triggered. If we assume this, the important anti-inflammatory effects at the local level and the parent analgesic benefits alongside the savings of opioids are the foundation to consider this technique in our therapeutic armament in the treatment of acute postoperative pain.
The Airtraq device can be an affordable and safe tool and well tolerated by patients requiring awake OTI. It requires a much shorter learning curve than FB and is used routinely in clinical practice which would provide more certainty to the procedure.
Marta Carrió Font, Sergio Tejada Ortega, Jorge Hernando Sáez, Nerea Martín Pauls, Paula Arrarte Ayuso, Javier Agulló Agulló.
University Hospital San Juan de Alicante