|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 4 | Page : 471-472
Nothing matters when you cannot breathe
Department of Anaesthesiology and Critical Care, Hindu Rao Hospital, New Delhi, India
|Date of Submission||30-Mar-2014|
|Date of Acceptance||28-Apr-2014|
|Date of Web Publication||28-Nov-2014|
DNB (Anaesht.), MBA (Hospital Management), 802, South Delhi Apartment, Sector 4, Dwarka, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandra A. Nothing matters when you cannot breathe. Ain-Shams J Anaesthesiol 2014;7:471-2
A supraglottic mass causing an obstruction of the glottis is a great challenge for intubation to the anesthesiologist . The situation becomes graver in emergency room with limited resources. We report a case of a 75-year-old fragile man with diabetes who presented to the emergency room with respiratory stridor; the relatives gave the history of sudden loss of consciousness with respiratory distress. The patient was in a state of shock, and it was decided to intubate the patient and shift him to the ICU for ventilation. He had a long beard with moustache with a single tooth in the oral cavity ([Figure 1]). On direct laryngoscopy with cricoid pressure after giving 2 mg of midazolam, the epiglottis was visible, but a supraglottic mass was visible. An attempt to intubate the patient with an adult-sized tube led to bleeding of the mass, and the tube could not be negotiated. There was imminent risk for aspiration of blood by the patient; hence, thorough suctioning was performed. A bougie, which was readily available, was introduced the moment glottic opening was visible, and a small-sized endotracheal tube no. 6.5 mm was railroaded over the bougie. The cuff was inflated and the tube was secured by bandage. Resuscitation was initiated immediately. Computed tomographic scan of the neck when performed revealed a large supraglottic mass ([Figure 2]); tracheostomy was further planned with gradual weaning from the ventilator.
A method using a flexible bronchoscope is recommended for patients with a supraglottic mass with difficulty in intubation. However, its use is limited in the event of hemorrhage or when considerable amounts of secretion such as sputum are present . However, our institution does not have the facility of using fiberoptic bronchoscope in the casualty. Although an laryngeal mask airway (LMA) was available, it was not used because of the risk for aspiration and the presence of blood in the oral cavity. Despite numerous studies comparing different supraglottic airway devices in manikins, there are few randomized controlled trials comparing different supraglottic airway devices in patients with difficult airway. Therefore, most safety data come from extended use rather than high-quality evidence, and claims of efficacy and particularly safety must be interpreted cautiously . The importance of rapid cricothyroidotomy in patients for emergency ventilation is emphasized , but as the patient had a long beard it was not feasible and the extent of tumor was not known as well.
Although guidelines for difficult airway management have been published, the extent to which consultant anesthesiologists follow these guidelines has not been determined. No substantial changes in airway management in a 'cannot intubate, cannot ventilate' scenario were observed after an intense 1-h personalized video-assisted airway-focused simulation debriefing session with an expert. It appears that multiple factors other than airway algorithms come into play in emergency airway decision-making processes, including one's personal clinical experience with the many available airway devices .
Thus, in emergency situations where conditions are not ideal, instruments are not working optimally, patients have comorbidities with limited physiological reserve, and where there is no time for proper airway assessment, nothing matters other than establishing a patent airway with the available gadgets.
| Acknowledgements|| |
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[Figure 1], [Figure 2]