An Association of Predicted/Unpredicted Difficult Intubation with Fibreoptic Bronchoscopic Intubation

Öz

Aim: Inadequate preoperative airway assessment is one of the most common causes of failed airway management and intubation. Fibreoptic bronchoscopic intubation (FBI) is an effective technique for creating airway access in patients with expected and unexpected difficult airways. The aim of this study is to evaluate the incidence of predicted difficult airway (DA) in patients intubated due to DA with FBI. Materials and Methods: We retrospectively reviewed the medical records of one hundred and forty ASA I-V patients aged 0-80 years diagnosed with DA who underwent flexible FBI from January 2006 to December 2011. Age, weight, sex, Mallampaty score, concomitant congenital syndrome, whether difficult intubation (DI) occurred after trauma, whether FBI was applied via nasal or oral ways, size of the tube, whether FBI was successful or not and relationships of these parameters were analysed. Results: The study involved 143 patients, 38 (22.2%) in the pediatric group and 105 patients (77.8%) in the adult group. Of the patients, 64 (47.4%) were female and 71 (52.6%) were male. DI was performed on 42 patients due to congenital anomalies. As a result of the preoperative anaesthetic assessment, DI could be predicted in 74 patients (51.7%) by history, physical examination and Mallampati scoring, while unexpected DI occurred in 69 (48.3%) of patients. The proportion of predicted DA was much higher in children compared to adults. Conclusion: It is not easy to check all predictors of DI in a pre-anaesthetic examination and the predictors are not accurate. Unexpected DI is not a rare occurrence in the operating room (OR). Despite a thorough pre-operative assessment, anaesthetists may not be able to predict what they will encounter during surgery and therefore should always be prepared for any challenge.

Anahtar Kelimeler

• Preoperative assessment
• predicted difficult intubation
• fiberoptic bronchoscopic intubation
• congenital airway abnormalities

An Association of Predicted/Unpredicted Difficult Intubation with Fibreoptic Bronchoscopic Intubation

Öz

Aim: Inadequate preoperative airway assessment is one of the most common causes of failed airway management and intubation. Fibreoptic bronchoscopic intubation (FBI) is an effective technique for creating airway access in patients with expected and unexpected difficult airways. The aim of this study is to evaluate the incidence of predicted difficult airway (DA) in patients intubated due to DA with FBI. Materials and Methods: We retrospectively reviewed the medical records of one hundred and forty-three ASA I-V patients aged 0-80 years diagnosed with DA who underwent flexible FBI from January 2006 to December 2011. Age, weight, sex, concomitant syndromes, whether difficult intubation (DI) occurred after trauma, whether FBI was applied via nasal or oral ways, size of tube, whether FBI was successful or not and relationships of these parameters were analysed. Results: The study involved 143 patients, 38 (22.2%) in the pediatric group and 105 patients (77.8%) in the adult group. Of the patients, 64 (47.4%) were female and 71 (52.6%) were male. 42 patients underwent DI for syndromes with craniofacial abnormalities. As a result of preoperative anaesthetic assessment, DI could be predicted in 74 patients (51.7%) by history, physical examination and Mallampati scoring, while unexpected DI occurred in 69 (48.3%) of patients. The proportion of predicted DA was much higher in children compared to adults. Conclusion: It is not easy to check all predictors of DI in a pre-anaesthetic examination and the predictors are not accurate. Unexpected DI is not a rare occurrence in the operating room (OR). Despite a thorough pre-operative assessment, anaesthetists may not be able to predict what they will encounter during surgery and therefore should always be prepared for any challenge. Keywords: Preoperative assessment, predicted difficult intubation, fiberoptik bronchoscopic intubation, syndromes with craniofacial abnormalities

Anahtar Kelimeler

• Preoperative assessment
• predicted difficult intubation
• fiberoptik bronchoscopic intubation
• syndromes with craniofacial abnormalities

Kaynakça

1. 1-Lundstrom LH, Moller AM, Rosenstock C, Astrup G, Gatke MR, Wetterslev J, et al. A documented previous difficult tracheal intubation as a prognostic test for a subsequent difficult tracheal intubation in adults. Anaesthesia 2009;64:1081-1088.
2. 2. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-270.
3. 3. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American society of anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology 2022;136:31-81.
4. 4. Calder I. Murphy P. A fibre-optic endoscope used for nasal intubation. Anaesthesia 1967; 22:489-91. Anesthesia 2010;65(11):1133-6. http://doi.org(10.1111/j.1365-2044.2010.06535.x
5. 5. Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004; 17:483-4484.
6. 6. Wanderer JP, Ehrenfeld JM, Sandberg WS, Epstein RH. The changing scope of difficult airway management. Can J Anaesth 2013; 60:1022-1024.
7. 7. Wong J, Lee JSE, Wong TGL, Igbal R, Wong P. Fiberoptic intubation in airway management: a review article. Singapore Med J 2019;60(3):110-118. http://doi.org/10.11622/smed,2018081
8. 8. Russo SG, Becke K. Expected difficult airway in children. Anesthesiology 2015;28(3):321-326.

9. 9. Rosenblatt WH, Yanez ND. Adcision tree approach to airway management pathways in the 2022 difficult airway algorithm of the American Society of Anesthesiologits. 2022, Anesthesia-Analgesia 2022;134(5):910-915.
10. 10. Rodrigues AJ, Scordamaglio PR, Palomino AM, Oliveria EQ, Jacomelli M, Figueiredo VR. Difficult airway intubation with flexible bronchoscope. Rev Bras Anesthesiol. 2013;63(4):358-361.
11. 11. Campling EA, Devlin HB, Hoile RW, Lunn JN. The report of the National Confidential Enquiry into Perioperative Deaths 1992/1993. London: National Confidential Enquiry into Perioperative Deaths; 1995. www.ncepod.org.uk/pdf/1992_3/Full Report 1992-1993.pdf. Accessed May 2, 2014.
12. 12. Bhat R, Mane RS, Patil MC, Suresh SN. Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome. Saudi J Aneaesth. 2014;8(3):412-414. http://doi.org/10.4103/1658-354X.136637
13. 13. Lee JJ, Lim BG, Lee MK, Kong MH, Kim JK, Lee JY. Fiberoptic intubation through a laryngeal mask airway as a management of difficult airwary due to the fusion of the entire cervical spine-A report of two cases. Korean J Anesthesiol 2012;62:272-276.
14. 14. Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a metaanalysis involving 177088 patients. British Journal of Anaesth 2011;107(5): 659-667. http://doi.org/10.1093/bja/aer292
15. 15. Hosking J, Zoanetti D, Carlyle A, Anderson P, Costi D. Anesthesia for Treacher Collins syndrome: a review of airway management in 240 pediatric cases. Paediatr Anaesth 2012; 22(8):752-758. http://doi.org/10.1111/j.1460-9592.2012.03829.x
16. 16. Marston AP, Lander TA, Tibesar RJ, Sidman JD. Airway management for intubation in newborns with Pierre Robin sequence. Laryngoscope 2012;122(6):1401–1404. http://doi.org/ 10.1002/lary.23260
17. 17. Stricker PA, Budac S, Fiadjoe JE, Rehman MA. Awake laryngeal mask insertion followed by induction of anesthesia in infants with the Pierre Robin sequence. Acta Anaesthesiol Scand 2008; 52(9):1307–1308. http://doi.org/10.1111/j.1399-6576.2008.01751.x
18. 18. Lim CH, Kim YJ, Kim JH, Jeong JS. Retrospective analysis of difficult entubation. Ewha Med J. 2017;40(3):115-121. http://doi.org/10.12771/emj.2017.40.3.115
19. 19. Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT. Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology 2017; 127(3):432-440. http://doi:10.1097/ALN.0000000000001758