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LETTER TO THE EDITOR
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 95-96

Fiberoptic bronchoscope assisted difficult airway management in maxillofacial trauma


Department of Anaesthesia, Jai Prakash Narayan Apex Trauma Centre (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India

Date of Web Publication26-Jul-2011

Correspondence Address:
Pramendra Agrawal
Senior Resident, Anesthesiology, A-148, Sector-15, Noida - 201 301, Uttar Pradesh
India
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DOI: 10.4103/2231-0746.83146

PMID: 23479555

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How to cite this article:
Agrawal P, Gupta B, D'souza N, Bhatnagar N. Fiberoptic bronchoscope assisted difficult airway management in maxillofacial trauma. Ann Maxillofac Surg 2011;1:95-6

How to cite this URL:
Agrawal P, Gupta B, D'souza N, Bhatnagar N. Fiberoptic bronchoscope assisted difficult airway management in maxillofacial trauma. Ann Maxillofac Surg [serial online] 2011 [cited 2019 Nov 13];1:95-6. Available from: http://www.amsjournal.com/text.asp?2011/1/1/95/83146

Dear Sir,

Airway maintenance with cervical spine control is the first priority in the assessment and management of any patient suffering from trauma. [1] We report a case wherein a potential difficult airway was successfully managed using the fiber optic bronchoscope (FOB).

A 45-year-old male was brought to the Emergency Department after a firearm injury. He was conscious, responsive with Glassgow Coma Score (GCS) 15/15, stable hemodynamic parameters and a large wound on the right side of the face [Figure 1]. Non-contrast computed tomography (NCCT) revealed right parietal extradural hematoma (EDH), right front temporo parietal (FTP) acute subdural hematoma (SDH), right globe rupture with fracture roof of orbit and squamous temporal bone [Figure 2]. NCCT cervical spine showed no abnormality. Right FTP decompressive craniotomy, evacuation of parietal EDH, duraplasty along with enucleation of eye ball, debridement of facial wound and removal of pellets were planned. Airway was secured by awake orotracheal FOB-guided intubation [Figure 3]. Upper airway was anesthetized using ultrasonic nebulisation of 5 ml of 4% xylocaine for 10 min. Anesthesia was induced with propofol, fentanyl and rocuronium and maintained with 60% nitrous oxide in oxygen, isoflurane, fentanyl and vecuronium. Post-operatively, ventilation was continued in the Intensive Care Unit. Five days post-operatively, he was tracheostomised, anticipating prolonged ventilation. The patient succumbed as a consequence of sepsis 12 days post-injury.
Figure 1: Patient after gunshot injury

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Figure 2: Non-contrast computed tomography showing globe rupture

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Figure 3: Bronchoscopic view of the vocal cords

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Anatomic distortion of airway in the form of bony disruption, soft tissue swelling and an increased potential for aspiration of body fluids in massive facial trauma poses major risks in airway management. [2] The facial disfiguration caused ineffective mask ventilation. The advantage of skillful, experienced personnel in airway management has been established in several studies. Schmidt et al. prospectively investigated emergent tracheal intubations [3],[4] and found that supervision by an attending anesthesiologist was associated with a decreased incidence of complications. The challenge in performing endotracheal intubation arises mainly from the difficulty in visualizing the vocal cords. Numerous airway devices and equipments have been developed to overcome this obstacle. [5],[6] FOB intubation under local anesthesia is the technique of choice for the management of the anticipated difficult intubation and mask ventilation. [7] The option of FOB intubation is suitable for elective procedures, but has been considered difficult in maxillofacial trauma patients with intraoral bleed. Blood, vomitus and secretions in the patient's airway hamper proper visualization by fiberoptic instruments. In addition, accomplishing effective local anesthesia in the traumatized region is difficult. Furthermore, the patient's cooperation is essential for such an approach. The final option is creating a surgical airway. The major complications of FOB include pneumothorax, pulmonary hemorrhage and respiratory failure. The minor complications include laryngospasm, vomiting, bronchospasm and episodes of vasovagal syncope. In our patient, upper airway anesthesia was successfully achieved using ultrasonic nebulisation, and FOB could be performed as there was no active bleed inside the oropharynx. This avoided the necessity for a surgical airway, which has its inherent complications. Extubation was deferred anticipating a high risk for complications in the post-operative period. [8]

A cooperative patient, availability of the fiberoptic scope and the expertise of the anesthesiologist enabled us to manage the procedure. Fiberoptic scope is a useful adjunct to emergency airway management in facial trauma.

 
  References Top

1.American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors ATLS. 7 th ed. Chicago, IL: American College of Surgeons; 2004.  Back to cited text no. 1
    
2.Cantrill SV. Massive facial trauma and direct Neck Trauma. In: Dailey RH, Simon B, Young GP, Stewart RD, editors. The Airway: Emergency Management. Mosby Year book Inc; 1992. p. 259-69.   Back to cited text no. 2
    
3.Schmidt UH, Kumwilaisak K, Bittner E, George E, Hess D. Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology 2008;109:973-7.  Back to cited text no. 3
    
4.Hodzovic I, Petterson J, Wilkes AR, Latto IP. Fibreoptic intubation using three airway conduits in a manikin: The effect of operator experience. Anaesthesia 2007;62:591-7.  Back to cited text no. 4
    
5.Hagberg C, Lam N, Brambrink A. Current concepts in airway management in the operating room: A new approach to the management of both complicated and uncomplicated airways. Curr Rev Clin Anesth 2007;28:73-88.  Back to cited text no. 5
    
6.Rabitsch W, Schellongowski P, Staudinger T, Hofbauer R, Dufek V, Eder B, et al. Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians. Resuscitation 2003;57:27-32.  Back to cited text no. 6
    
7.American Society of Anesthesiologists Task Force on Management of the Difficult Airway: 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 2003;98:1269-77.  Back to cited text no. 7
    
8.Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: A closed claims analysis. Anesthesiology 2005;103:33-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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