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Planned lightwand intubation in a patient with a known difficult airway

Rome, Italy

To the Editor:

Difficulty in managing the airway is the single most important cause of anesthesia-related morbidity and mortality. Unfortunately, intubation under direct vision may be difficult or impossible in 1% to 3% of the general surgical population¹ and 0.05% to 3.5% of obstetric patients.² In 91.9% of difficult intubations, only the epiglottis can be visualized during laryngoscopy (grade III according to the Cormack and Lehane classification). During the last decades, several intubating techniques have been suggested in case of difficult laryngoscopy. Light-guided intubation using the principle of transillumination has proven to be an effective and simple technique.³ The Trachlight^TM (Laerdal Medical AS, Stavanger, Norway) has been suggested as a useful option in the case of difficult or impossible laryngoscopic intubation for both anticipated and unanticipated situations. This lightwand intubating technique is also recommended as the first-line option in patients who can be ventilated but have a failed laryngoscopic intubation.² In the literature there are few cases of known difficult airway managed electively with this device.⁴

We report the case of a 64-yr-old woman, 60 kg, 160 cm, who underwent an elective laparoscopic gynecologic surgical procedure. The patient had a history of failed laryngoscopic intubation but there were no foreseen difficulties in face mask ventilation. Clinical examination of the patient showed a Mallampati grade III airway, a short neck (thyromental distance of 3.8 cm), a mild reduction of neck extension, and an interincisive distance of 2.5 cm. As it was easy to ventilate the patient, we decided to achieve tracheal intubation with a lightwand.

One hundred percent oxygen was administered to the patient via a face mask for five minutes. General anesthesia was induced with propofol 2 mg•kg^–1, fentanyl 3 µg•kg^–1 and succinylcholine 1 mg•kg^–1. When fasciculations were visible, a direct laryngoscopy was performed to verify the intubation grade. As a Cormack grade III was visible, intubation with a light-wand was attempted. A right lateral transilluminating glow was observed immediately in the neck. After partially withdrawing and repositioning the lightwand in the midline, an optimal and central transilluminating glow was promptly visible on the cricothyroid membrane. A cuffed 7-mm internal diameter tracheal tube was threaded over the lightwand into the patient’s trachea. Intubation time, recorded from insertion of the lightwand into the mouth to the first positive capnography was 8.7 sec. The endotracheal tube was connected to the mechanical ventilator and the surgical procedure was carried out without any complication.

The present case report further confirms that light-wand (Trachlight^TM) intubation can be effective in cases of foreseen difficult intubation when there are no known or suspected difficulties with face mask ventilation.

References

1 Ovassapian A, Meyer RM. Airway management. In: Longnecker JH, Tinker JH, Morgan GE (Eds). Principles and Practise of Anesthesiology, 2nd ed. Mosby; 1998: 1064–99.

2 Hung OR, Pytka S, Morris I, Murphy M, Stewart RD. Lightwand intubation: II - Clinical trial of a new ligth-wand for tracheal intubation in patients with difficult airways. Can J Anaesth 1995; 42: 826–30.[Abstract/Free Full Text]

3 Agrò F, Hung OR, Cataldo R, Carassiti M, Gherardi S. Lightwand intubation using the Trachlight^TM: a brief review of current knowledge. Can J Anesth 2001; 48: 592–9.[Abstract/Free Full Text]

4 Agrò F, Brimacombe J, Marchionni L, Carassiti M, Cataldo R. Nasal intubation with the Trachlight (Letter). Can J Anesth 1999; 46: 907–8.[Medline]

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