Table of Contents  
LETTER TO THE EDITOR
Year : 2014  |  Volume : 7  |  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 Submission30-Mar-2014
Date of Acceptance28-Apr-2014
Date of Web Publication28-Nov-2014

Correspondence Address:
Alka Chandra
DNB (Anaesht.), MBA (Hospital Management), 802, South Delhi Apartment, Sector 4, Dwarka, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.145658

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How to cite this article:
Chandra A. Nothing matters when you cannot breathe. Ain-Shams J Anaesthesiol 2014;7:471-2

How to cite this URL:
Chandra A. Nothing matters when you cannot breathe. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 Sep 15];7:471-2. Available from: http://www.asja.eg.net/text.asp?2014/7/4/471/145658

A supraglottic mass causing an obstruction of the glottis is a great challenge for intubation to the anesthesiologist [1]. 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.
Figure 1: Beard of the patient.

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Figure 2: The supraglottic mass.

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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 [2]. 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 [3]. The importance of rapid cricothyroidotomy in patients for emergency ventilation is emphasized [4], 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 [5].

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 Top


 
  References Top

1.
Bradley PJ. Treatment of the patient with upper airway obstruction caused by caner of the larynx. Otolaryngol Head Neck Surg 1999; 120:737-741.  Back to cited text no. 1
[PUBMED]    
2.
Kanaya N, Nakayama M, Seki S, Kawana S, Watanabe H, Namiki A. Two-person technique for fiberscope-aided tracheal intubation in a patient with a long and narrow retropharyngeal air space. Anesth Analg 2001; 92:1611-1613.  Back to cited text no. 2
    
3.
Timmermann A. Supraglottic airways in difficult airway management: success, failures, use and misuse. Anaesthesia 2011; 66:1365-2044.  Back to cited text no. 3
    
4.
Schecter WP, Wilson RS. Management of upper airway obstruction in the intensive care unit. Crit Care Med 1981; 9:577-579.  Back to cited text no. 4
[PUBMED]    
5.
Borges BC, Boet S, Siu LW, Bruppacher HR, Naik VN, Riem N, Joo HS. Incomplete adherence to the ASA difficult airway algorithm is unchanged after a high-fidelity simulation session. Can J Anaesth 2010; 57:644-649.  Back to cited text no. 5
    


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