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Correspondence |
Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’ s Republic of China. E-mail: fruitxue{at}yahoo.com.cn
To the Editor:
Whenever difficulty in ventilation and laryngoscopic intubation is anticipated, awake fibreoptic intubation is often the safest option.1 However, effective local anesthesia of the airway is mandatory for patient comfort and subsequent successful instrumentation.2 The "spray as you go" technique using fibreoptic bronchoscope (FOB) provides flexibility in selectively anesthetizing respiratory passages, but cannot provide topical anesthesia as effectively as transtracheal injection of lidocaine.3 This may be related to the fact that local anesthetic injected by the working channel of FOB or epidural catheter cannot be reduced to extremely fine cloud-like particles. The MADgic® atomizer (Wolfe Tory Medical Inc., Salt Lake City, UT, USA) is a new device that has the ability to provide atomized topical solution directly to the airway mucosa.4 One of its disadvantages is the requirement for direct laryngoscopy to provide access to the pharynx, larynx and trachea, which may cause airway stimulation that the awake patient cannot well tolerate. In contrast, exposure of the airway structures using a FOB can attenuate or even avoid direct airway stimuli. We have successfully combined a FOB (Olympus LF-DP or LF-TP, Tokyo, Japan) and a MADgic® atomizer to provide topical anesthesia of the hypopharynx, larynx and trachea before tracheal intubation.
This combined technique requires an elastic 5 mm lactoprene tube 3 cm in length. The lumen of the lactoprene tube is well lubricated using a water-soluble lubricant. Both the distal bending section of the FOB and the applicator portion of the MADgic® atomizer are inserted into the lactoprene tube until their tips protrude just beyond the distal end of lactoprene tube (Figure
). With local Ethics Committee approval, 15 patients scheduled for elective surgery who had a predicted difficult intubation gave written informed consent to participate in a clinical evaluation of this combined technique. Of the 15 patients, three had limited mouth opening (inter-incisor distance of 18–22 mm), 11 had limited extension of the head, and one patient had micrognathia (thyromental distance of 4.2 cm).
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In all patients the FOB-MADgic® unit was successfully directed to the different targeted areas using one to two attempts. After the final spray, the mean visual analogue scores for pain, anxiety and coughing were 7.8 ± 1.3, 6.5 ± 1.7 and 5.2 ± 1.5, respectively (where 0 was described as awful and 10 as enjoyable). All subjects reported the airway spray of lidocaine to have been acceptable; two found it enjoyable. The time from start to final spray of lidocaine using the FOB-MADgic ® unit ranged from 21 to 28 min. The median dose of lidocaine was 2.5 mg·kg–1 (range 2.1–2.8 mg·kg–1). No patient experienced any local anesthetic side-effect and fibreoptic intubation was successfully completed on the first attempt in all patients. During the procedure, patient reaction scores (no reaction = 1, slight grimacing = 2, strong grimacing = 3, verbal objection = 4, defensive movement of the head, hands or feet = 5)5 were 1.9 ± 0.6 with nasotracheal intubation and 1.6 ± 0.7 with orotracheal intubation, respectively.
According to this preliminary experience, we consider that using a combination of FOB and MADgic® atomizer for airway topical anesthesia has several advantages. First, it can provide excellent topical anesthesia of the airway. Second, this technique is well tolerated by the awake sedated patient. Third, it is non-invasive and therefore has minimal risk of airway damage. Fourth, there is no restriction on the patients’ head and neck position. However, it must be pointed out that a limitation of this technique is its inability to anesthetize the nasal mucosa. To reduce airway damage caused by repeated manipulation, the FOB-MADgic® unit should not be inserted through the nasal cavity, because it has an external diameter of about 6–8 mm.
Footnotes
Accepted for publication August 8, 2007.
References
1 Kundra P, Kutralam S, Ravishankar M. Local anaesthesia for awake fibreoptic nasotracheal intubation. Acta Anaesthesiol Scand 2000; 44: 511–6.[Medline]
2 Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med 2002; 27: 180–92.[Medline]
3 Graham DR, Hay JG, Clague J, Nisar M, Earis JE. Comparison of three different methods used to achieve local anesthesia for fiberoptic bronchoscopy. Chest 1992; 102: 704–7.[Medline]
4 Supbornsug K, Osborn IP. Topicalization of the airway using the glidescope. Anesth Analg 2004; 99: 1263–4.
5 Puchner W, Egger P, Puhringer F, Lockinger A, Obwegeser J, Gombotz H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand 2002; 46: 350–4.[Medline]
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  N. He, F. S. Xue, Y. C. Xu, X. Liao, and X. Z. Xu Awake orotracheal intubation under airway topical anesthesia using the Bonfils in patients with a predicted difficult airway Can J Anesth, December 1, 2008; 55(12): 881 - 882. [Full Text] [PDF]
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S. M. Neustein Topicalization of the airway for fibreoptic intubation Can J Anesth, April 1, 2008; 55(4): 251 - 252. [Full Text] [PDF]
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