Teena Bansal, Jatin Lal
Department of Anaesthesiology & Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak-124001,(Haryana), (INDIA)
Correspondence: Dr. Teena Bansal
19/6 J, Medical Campus, PGIMS, Rohtak-124001 (Haryana) (India),
E-mail: aggarwalteenu@rediffmail.com; Mobile: +91-9315839374
Mask ventilation is the most basic step in airway management. There are certain situations where mask ventilation is difficult,1 but sometimes it may be really impossible as in this 30 year male patient with facial burns. He suffered from burns one and a half month back due to episode of seizure. Burns were present over face, neck, chest and shoulders. On examination, mouth opening was less than one cm. Teeth were loose. Neck movements were restricted. Left nares was only partially patent. Respiratory and cardiovascular systems were unremarkable. Relevant laboratory investigations were within normal limits. Mask ventilation was not feasible. So awake nasal fiberoptic intubation was planned.2,3 The procedure was explained to the patient and consent was taken for the same. He was given alprazolam 0.25 mg and ranitidine 150 mg at night and 2 h before surgery.
Preoperatively nose was decongested with xylometazoline nasal drops. Glycopyrrolate 0.2 mg and fentanyl 30 µg were given intravenously. Nebulization was done with xylocaine. Xylocaine jelly was instilled into right nostril and nasoparyngeal airway 6 mm was put gently. Fiberscope loaded with flexometallic tube of internal diameter 6 mm was passed through it. After visualization of glottis, larynx was sprayed with 2 ml of lignocaine 2% through the injection port of fiberscope and trachea was intubated successfully (Figure).
Anesthesia was induced with propofol 120 mg, fentanyl 100 µg and vecuronium 5 mg. Anesthesia was maintained with 67 % nitrous oxide in oxygen, sevoflurane and vecuronium. Surgery lasted for 3 h. At the end of surgery, neuromuscular blockade was reversed and trachea was extubated awake.
In case of difficult mask ventilation, alternative techniques must be kept in mind.2 Although LMA or i-gel have been used as an alternative under sedation or light anesthesia, in the presence of restricted mouth opening the safest approach remains awake fiberoptic intubation.3
(Permission to publish the picture was obtained from the patient).
REFERENCES
Department of Anaesthesiology & Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak-124001,(Haryana), (INDIA)
Correspondence: Dr. Teena Bansal
19/6 J, Medical Campus, PGIMS, Rohtak-124001 (Haryana) (India),
E-mail: aggarwalteenu@rediffmail.com; Mobile: +91-9315839374
Mask ventilation is the most basic step in airway management. There are certain situations where mask ventilation is difficult,1 but sometimes it may be really impossible as in this 30 year male patient with facial burns. He suffered from burns one and a half month back due to episode of seizure. Burns were present over face, neck, chest and shoulders. On examination, mouth opening was less than one cm. Teeth were loose. Neck movements were restricted. Left nares was only partially patent. Respiratory and cardiovascular systems were unremarkable. Relevant laboratory investigations were within normal limits. Mask ventilation was not feasible. So awake nasal fiberoptic intubation was planned.2,3 The procedure was explained to the patient and consent was taken for the same. He was given alprazolam 0.25 mg and ranitidine 150 mg at night and 2 h before surgery.
Preoperatively nose was decongested with xylometazoline nasal drops. Glycopyrrolate 0.2 mg and fentanyl 30 µg were given intravenously. Nebulization was done with xylocaine. Xylocaine jelly was instilled into right nostril and nasoparyngeal airway 6 mm was put gently. Fiberscope loaded with flexometallic tube of internal diameter 6 mm was passed through it. After visualization of glottis, larynx was sprayed with 2 ml of lignocaine 2% through the injection port of fiberscope and trachea was intubated successfully (Figure).
Anesthesia was induced with propofol 120 mg, fentanyl 100 µg and vecuronium 5 mg. Anesthesia was maintained with 67 % nitrous oxide in oxygen, sevoflurane and vecuronium. Surgery lasted for 3 h. At the end of surgery, neuromuscular blockade was reversed and trachea was extubated awake.
In case of difficult mask ventilation, alternative techniques must be kept in mind.2 Although LMA or i-gel have been used as an alternative under sedation or light anesthesia, in the presence of restricted mouth opening the safest approach remains awake fiberoptic intubation.3
(Permission to publish the picture was obtained from the patient).
REFERENCES
- El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anaesth Analg 2009;109:1870-80. [PubMed] [Free full text] DOI: 10.1213/ANE.0b013e3181b5881c
- Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006;105:885-91. [PubMed] [Free full text] DOI: 10.1097/00000542-200611000-00007
- Biebuyck JF, Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087-110. [PubMed] [Free full text] DOI: 10.1097/00000542-199112000-00021