Difficult airway intubation with flexible bronchoscope

Airway challenges in bilateral temporomandibular joint ankylosis with adenoid hypertrophy: a case report

Temporomandibular joint ankylosis is one of the most challenging airway disorders associated with varying anatomical abnormalities like adenotonsillar hypertrophy, craniofacial malformations, macroglossia, etc. This case highlights the intubation difficulties confronted during the airway management of a 10-year-old girl presenting lately with bilateral temporomandibular joint ankylosis, hypoplastic mandible, and adenoid hypertrophy. This patient was intubated successfully by using a suction catheter assembly to negotiate the endotracheal tube across the adenoid, and an unmatched-size flexible intubation fiberscope through a "separate insertion" technique and external laryngeal manipulation. This case emphasises the significance of a comprehensive preoperative evaluation in preparing the anaesthetic plan of an anticipated difficult airway in a paediatric population, having diverse anatomical hurdles presenting concurrently.

Time to tracheal intubation over a fibreoptic bronchoscope using a silicone left double-lumen endobronchial tube versus polyvinyl chloride single-lumen tube with bronchial blocker: a randomized controlled non-inferiority trial

Background

Direct insertion of a double-lumen endobronchial tube (DLT) over a fibreoptic bronchoscope (FOB) is considered more difficult and traumatic than that of a single-lumen tube (SLT). We hypothesized that time to intubation over an FOB using a silicone left DLT would be non-inferior to that using a polyvinyl chloride (PVC) SLT.

Methods

Eighty patients were enrolled in this open-label, randomized controlled, non-inferiority trial. Patients were randomly allocated to fibreoptic tracheal intubation with either a silicone DLT or PVC SLT (DLT and SLT groups, respectively). Time to tracheal intubation [time to insertion of FOB plus railroading (advancement over the FOB) time]; total time for correct tube and bronchial blocker positioning; difficulty of railroading; and the incidence of sore throat, swallowing difficulty, and hoarseness were compared between groups.

Results

The median time to intubation over the FOB was 20 s in the DLT group and 23 s in the SLT group. The upper limit of the confidence interval of this difference was below the non-inferiority margin of 10 s (median difference: -2 s; 95% confidence interval: -4 to 0 s). Railroading time was significantly shorter in the DLT group than in the SLT group (median time: 10 vs. 11 s; median difference: -1 s; 95% confidence interval: -3 to 0 s; P=0.03). Railroading over the FOB (rated on a four-point scale) was less difficult in the DLT group than in the SLT group (P<0.01).

Conclusions

Tracheal intubation using an FOB can be achieved at least as fast using the silicone DLT as using the PVC SLT. The silicone DLT exhibited superior railroading performance to the PVC SLT.