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addition, the right aortic arch externally compressed the lateral wall of the trachea. However, these abnormal findings were subtle and may have been easily overlooked if we had not carefully observed the region around the central shadows. It would have been impossible to correctly diagnose this case by routine preoperative examination alone. We would like to emphasize that vigilant evaluation of the chest X-ray film is the most important initial step leading to a diagnosis of a potentially serious illness such as DAA.
Declaration of interest None declared.
1 Dekeyzer S, Gosselin R, Delrue L. Silent double aortic arch in an elderly patient. JBR-BTR 2013; 96: 45 2 Ikenouchi H, Tabei F, Itoh N, Nozaki A. Images in cardiovascular medicine. Silent double aortic arch found in an elderly man. Circulation 2006; 114: e360–1 3 Kim HY, Jung HY, Yun TJ, et al. Three cases of dysphagia due to vascular ring in adults. Korean J Gastrointest Endosc 2000; 21: 735–40
doi:10.1093/bja/aeu168
Intubation in the operating theatre using the Video-AirtraqTM laryngoscope in difficult circumstances by a face-to-face tracheal intubation technique Editor—We have demonstrated that the Video-AirtraqTM laryngoscope (VAL; VYGON, Ecouen, France) used in difficult airway management simulation conditions, allowed fast and easy face-to-face oro-tracheal intubation (ftf-OTI) with the difficult airway manikin placed in sitting position facing the operator.1 After both manikin and clinical training, and after a clinical evaluation trial, we have incorporated VAL-ftf-OTI technique in our difficult airway management algorithm. We propose the VAL-ftf-OTI technique as a standard to elective/emergency operating theatre patients showing an inter-incisor distance or mouth aperture of .25 mm, necessitating a second tracheal intubation (re-intubation) after the first one, attempted with the Macintosh laryngoscope (ML), had been difficult, as defined by an intubation difficulty score2 (IDS) of .5, in the condition of a difficult airway management algorithm.3 Four trained clinicians were filmed during the airway management of seven adult patients. Before induction of
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Y. Suzuki 1* Y. Nishikawa1 D. Horiuchi1 K. Semba1 T. Fujii1 T. Higaki2 Y. Takasaki 1 1 Uwajima, Japan 2 Toon, Japan *E-mail:
[email protected]
anaesthesia, standard monitors were placed and optimal preoxygenation was performed. The operator stood/sat on the right side of the patient in the beach-chair/operating table (n¼3) or sitting/bed (n¼4) position. The video-screen was placed lateral to the patient at the level of the operator’s eyes. With FEO2 .90%, anaesthesia was induced with sufentanil 20 mg kg21 followed 1 min later by propofol 2 mg kg21, and succinylcholine 1 mg kg21. Then, the operators followed a simple VAL soft insertion procedure in the oral cavity and pharynx. With optimal glottis view, the tracheal tube was pushed into the trachea or railroaded over an Eschmann stylet inserted first in the trachea under the control of view and blocked distally in the bronchial tree. The airways of the seven (IDS.5) patients were rapidly, easily, and safely secured using the VAL-ftf-OTI technique. Table 1 gives details of initial difficult tracheal intubation and those of face-to-face Video-AirtraqTM -assisted tracheal re-intubation with the patients placed in the beach-chair/ sitting position. This observation is spectacular in such anticipated difficult airway patients. Shortening, facilitating, and securing airway management is certainly of major interest in anticipated difficult airway patients exposed to high risk of both arterial oxygen desaturation and aspiration. Our results are certainly linked to the skill of the four operators who performed this technique. However, such performance also results from both the characteristics of VAL over ML and the position of the patient. First, VAL blade, when compared with that of ML, has an anatomical shape and is thinner, allowing viewing the glottis (Cormack and Lehane grade of 1 and 2) with very low anatomical constraints, even in the difficult airway patients.3 – 5 Secondly, the necessary dexterity requested for TI with a channelled device is much lower than that of ML. Indeed, tracheal intubation using a channelled device such as the VAL requires just a single hand skill, to optimize distal blade position in the pharynx. The second hand is only used to push forward the tube charged in its channel. Thirdly, the sitting position simplifies VAL blade insertion, because it prevents tongue muscle mass falling posterior, sparing some space in the oral cavity to identify anatomy and optimally position the VAL blade. These three elements contributed to the ease of VAL-ftf-OTI technique in the difficult airway cases we report. In addition, the position of the patient permitted gravity securing the airway management by increasing pulmonary oxygen store before apnoea, reducing the risk of both regurgitation and aspiration, and reducing the possibility that pharyngeal secretions alter the view of the anatomy using VAL. The ML requires certain positioning between the operator and the patient, in which the ML is required to be moved towards the glottis against gravity in a narrowed or collapsed pharynx. VAL allows rapid access to the trachea under the video control of view. The VAL-ftf-OTI technique eases, and secures anticipated difficult airway management in patients probably placed in the safest position for airway management. Clinical trials evaluating VAL-ftf-OTI as primary
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Table 1 Details of initial difficult tracheal intubation and those of face-to-face Video-AirtraqTM - assisted tracheal re-intubation with the patients placed in the beach-chair/sitting position. Predictors: Number of difficult airway management predictors identified at the peroperative airway evaluation depicted from the following list: morbid obesity, sleep apnoea syndrome, Mallampati grade of 3 or 4, mouth aperture of ,30 mm, thyromental distance of ,70 mm, cervical perimeter measured at the level of thyroid cartilage of .45 cm in males and 40 cm in females, severe receded mandible, previous impossible tracheal intubation, severely fixed cervical spine; TI, tracheal intubation; ML, Macintosh laryngoscope; ES, Eschmann stylet; LMA-FT, LMA FastrachTM ; C&L, Cormack and Lehane grade of laryngoscopy view; IDS, calculated intubation difficulty score;2 SaO2 L, lowest SaO2 during airway management; TID, tracheal intubation duration, extracted from anaesthesia records (initial difficult airway management) or calculated on video-recorded films as the time elapsing between distal blade of the AirtraqTM laryngoscope enters the oral cavity and the cuff of the tube is inflated in the trachea. *Conventional use of the AirtraqTM laryngoscope with direct top lens vision; †conventional use of the AirtraqTM laryngoscope with the video-screen vision Predictors (n)
Face-to-face Video-AirtraqTM
Initial difficult airway management Failed devices
SaO2 L (%)
TID (s)
IDS
Successful devices
C&L AirtraqTM
Need ES
2
4
ML/ES
94
300
6
LMA-FT
1
—
5
3
ML/ES
68
300
6
LMA-FT
1
—
5
3
ML
91
240
6
ML/ES
1
4
4
ML/ES
91
360
6
LMA-FT
3
3
ML/ES/*AirtraqTM
94
240
7
TID (s)
IDS
98
25
0
96
20
1
—
100
30
0
1
—
96
23
1
†
2
—
100
18
3
4
ML/ES
98
240
1
6
LMA-FT
2
1
100
55
3
4
ML/ES
98
180
2
6
LMA-FT+fibrescope
2
1
100
20
1
airway management strategy are ongoing to confirm our observations.
Declaration of interest None declared. S. Zraier S. Bloc M. Chemit R. Amathieu G. Dhonneur* Cre´teil, France *E-mail:
[email protected] 1 Amathieu R, Sudrial J, Abdi W, et al. Simulating face-to-face tracheal intubation of a trapped patient: a randomized comparison of the LMA FastrachTM , the GlideScopeTM , and the AirtraqTM laryngoscope. Br J Anaesth 2012; 108: 140– 5 2 Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290– 7 3 Amathieu R, Combes X, Abdi W, et al. An algorithm for difficult airway management, modified for modern optical devices (AirtraqTM laryngoscope; LMA CTrachTM ): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114: 25– 33 4 Dhonneur G, Ndoko S, Amathieu R, Housseini LE, Poncelet C, Tual L. Tracheal intubation using the Airtraq in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology 2007; 106: 629– 30 5 Ndoko SK, Amathieu R, Tual L, et al. Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes. Br J Anaesth 2008; 100: 263– 8
doi:10.1093/bja/aeu170
AirtraqTM , ES
SaO2 L (%)
Use of the GlideScope in paediatric foreign body upper airway obstruction Editor—Paediatric upper airway obstruction due to foreign bodies can be challenging to manage and distressing for the patient and family. A multidisciplinary team including anaesthetists, otolaryngologists, and paediatricians must be involved so as to ensure expedient retrieval of the object without compromising the airway. In some cases, direct laryngoscopy can be challenging due to the presence of a foreign body in the upper airway and all possible adjuncts should be available before attempting extrication of the foreign body, including provision for a surgical airway. Video laryngoscopy using the GlideScope (Verathon Inc., Bothell, WA, USA) provides real-time video images of the upper airway to aid intubation, which is particularly useful when managing difficult airway situations. During one such situation of paediatric upper airway foreign body obstruction in our institution, the GlideScope facilitated safe extrication of the foreign body without jeopardizing the airway. The case was of a 7-yr-old male with no previous medical problems who was brought into the resuscitation room in the emergency department after suffering a respiratory arrest at home, after a choking episode. The history given by the parents did not suggest foreign body inhalation; however, X-ray imaging revealed a spherical foreign body in the upper airway. The child was immediately transferred to theatre with senior anaesthetic and otolaryngological teams present. Direct laryngoscopy was problematic due to the presence of a large marble lying on the top of the glottis, creating a ‘ball valve’ effect during respiration. The decision was made to utilize the GlideScope video laryngoscope, which enabled full visualization of the airway and obstructing foreign body (Fig. 1) and facilitated direct removal using Magill’s forceps.
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C&L ML
