Letter to the Editor commenting the study published in the journal by Ascedio Jose Rodrigues et al. (Rev Bras Anestesiol 2013;63(4):358-361), regarding flexible bronchoscopy intubation

Dear Editor,

I read the article by Ascedio Jose Rodrigues et al. published in the RBA (Rev Bras Anestesiol 2013;63(4):358-361), and I would like to expose some opinions about the awake flexible bronchoscopy intubation (FBI).

As highlighted in the study, FBI is not a good option for the situation "can't intubate, can't ventilate" (CICV), a situation that involves major threat to life.1 Fiberoptic intubation is safe, but requires time and skill and is not suitable in CICV situation that requires immediate restoration of ventilation.

I never applied blockade (with needles) for FBI, and the reason is that if the patient is able to open his mouth enough for intraoral access to perform the glossopharyngeal nerve block, by injection in the caudal portion of the posterior tonsillar pillar, this patient probably has an easy intubation and does not require FBI. More importantly, due to the proximity of the carotid artery, there is a possibility of intra-arterial injection, or worse, hematoma of the posterior region of the tongue, which would transform a difficult case in an impossible case.

Regarding superior laryngeal nerve block, it is only feasible in patients who do not need it; that is, in lean patients with well-defined anatomical landmarks. In obese patients, or patients using cervical collar or with cervical trauma, or those with short, thick neck ("taurine"), precisely those that would benefit from awake fiberoptic intubation, this blockade is no longer a good option.

I perform blockades "without needles" in my patients. In order to apply local anesthetics, I ask the patient to poke his tongue and then I hold it with a gauze. On each side, I apply two puffs of 10% lidocaine in the palatoglossal arch in an attempt to block the glossopharyngeal nerve in order to minimize the gag reflex; followed by an additional puff in the soft palate. After about 3 minutes, I place a gauze soaked in 10% lidocaine in the piriform fossa, behind the base of the tongue bilaterally. The objective is to block the nerves due to their proximity to the mucosa saturated with concentrated local anesthetic solution.2

Regarding bite block application, I recommend using one of oropharyngeal intubation cannulas. Although there are several on the market, I have available only the VBM^(r) and VAMA^(r) (Valentin Madrid). The main difference between them is that VAMA^(r) pushes the soft palate backward, while VBM pushes the tongue forward.3 With the use of these tubes, fibroscopy is MUCH easier (my emphasis): the fiberscope does not deviate from midline and is directed to the epiglottis, for anesthetic supplementation through the working channel of the fiberscope.4 With the use of these cannulas there is no need to disconnect the intermediate 22 mm device from tracheal cannula. I start with a careful titration of sedatives and administration of supplemental oxygen early in the procedure, in order to make the experience less unpleasant for the patient.

References

• 1. Practice guidelines for management of the difficult airway. Anes- thesiology. 2003;98.
• 2. Simmons ST, Scheich AR. Reg Anesth Pain Med. 2002;27(2): 180-92.
• 3. Gil KSL. Fiber-optic intubation: tips from the ASA Workshop. Anesthesiol News. 2012.
• 4. Castañeda Pascual M, Batllori Gastón M, Unzué Rico P, et al. Comparación de las cánulas VAMA y Berman para la intubación fibroscópica orotraqueal en pacientes anestesiados. Rev Esp Anestesiol Reanim. 2013;60: 134-41.

Publication Dates

• Publication in this collection
  Sep-Oct 2015