Abstract

Here, we report that, under the assistance of both the GlideScope and a fiberoptic bronchoscope, tracheal intubation was accomplished successfully in a 50-year-old woman with severe rheumatoid arthritis who underwent tongue lump resection under general anesthesia. Either the GlideScope or the fiberoptic bronchoscope alone failed to secure the airway; the use of both in combination facilitated airway intubation. This case report indicate that, even with careful preoperative assessment, patients who suffer from rheumatoid arthritis may have severe airway difficulty with intubation, and the combined use of the GlideScope and a fiberoptic bronchoscope can be a novel alternative for tracheal intubation in patients with severe airway difficulty.

Keywords

airway management: difficult; arthritis, rheumatoid; bronchoscopes; fiber Optic Technology; intubation, intratracheal; laryngoscopes: GlideScope;

1. Introduction

Difficult tracheal intubation can be anticipated in patients with rheumatoid arthritis due to ankylosis of the cervical spine, erosion of the temporomandibular joint, and deformities of laryngeal structures.¹ In most of the cases, a video-laryngoscope or a fiberoptic bronchoscope can help significantly in intubation of such patients.2, 3 Here, we report a case in which tracheal intubation was accomplished successfully using both a video-laryngoscope (GlideScope) and a fiberoptic bronchoscope in combination, under general anesthesia, in a patient suffering from severe rheumatoid arthritis.

2. Case report

A 50-year-old woman (height 156 cm, weight 50 kg) presented with a painless gradual augmented lump on the left tongue for 4 months and was scheduled for lump resection under general anesthesia. Her past medical history included rheumatoid arthritis for 17 years and severe osteoporosis for 4 years. She was treated with tosufloxacin and meloxicam without any adverse reactions and had no history of allergy to any medication. Physical examination indicated that her neck was stiff and significantly restricted backward. When she was supine, her head and the horizontal level formed an angle of about 30° (Fig. 1A). The preoperative airway evaluation revealed a mouth opening with an interdental distance of 25 mm; the patient was classified as Mallampati Class II because her soft palate, posterior palatine arch, and partial uvula were visible. Articular deformation of her fingers and toes was extremely evident. Preoperative laboratory examination results were normal.

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Fig. 1. (A) Angle (30°) between the patient's head and the horizontal level caused by rigidity of the cervical spine. (B) Schematic drawing of the setting of both the GlideScope and the bronchofibroscope during intubation.

Anesthesia was induced with fentanyl, propofol, and vecuronium after midazolam premedication. Initially, trachea intubation was tried via oral routine using the GlideScope after the cuff of a 7.0 F tracheal catheter was precoated with a lidocaine ointment. However, the image provided by the GlideScope could not provide a good visualization of the patient's glottis, and only about one-fifth of the epiglottis could be seen. The anterior extremity of the tracheal catheter was shaped in the form of a hook by bending the internal stylet, to facilitate blind intubation. The tip of the tracheal tube could reach the posterior wall of the pharynx crossing the epiglottis, but failed to progress further or easily dropped into the esophagus. The blood pressure, heart rate, oxygen saturation, and end tidal carbon dioxide were monitored during intubation, and mask oxygenation was initiated immediately when oxygen saturation decreased, keeping a standby laryngeal mask in case of facial mask oxygenation failure. After three failed attempts, nasotracheal intubation was carried out using a fiberoptic bronchoscope. A volume of about 0.5 mL ephedrine (30 mg/mL) was dropped into the right nostril for reducing the risk of nasal mucosa hemorrhage. A 6.5-F tracheal tube coated with paraffin oil was advanced into the oral cavity through the right nasal cavity, using a bronchoscope. Although the tip of the bronchoscope could be introduced into the pharynx and toward the laryngeal inlet, the glottis was still not visualized due to the lumen of the pharynx and larynx being smaller and the epiglottis being obstructive.

Then the laryngoscope blade of the GlideScope was put into the patient's mouth cavity again in an attempt to remove the obstruction of the tip of the bronchoscope caused by the epiglottis; meanwhile, the location of the bronchoscope was adjusted to facilitate the anterior extremity of the endotracheal tube to pass through the epiglottis under the video guide of the GlideScope. The glottis was visualized eventually by using the video-laryngoscope assisted with the bronchoscope. When the bronchoscope entered well into the trachea, the endotracheal tube was passed over the bronchoscope into the glottis with better finished off intubation. Anesthesia was maintained with propofol, remifentanil, and vecuronium; additionally, dexamethasone was administered prophylactically to reduce the incidence of postoperative throat edema. Intraoperative vital signs of the patient were stable. When the operation was over, extubation was carried out after the confirmation that the patient gained consciousness and was breathing spontaneously. Postoperatively, no complications related to tracheal intubation such as hoarseness or painful swallowing occurred. The lump was diagnosed as a chronic ulcer combined with inflammatory granulation tissue through a histological examination. The patient was discharged from the hospital 8 days after surgery.

3. Discussion

Rheumatoid arthritis is currently known as a chronic systemic inflammatory disorder characterized by deforming symmetrical polyarthritis of varying extent and severity, affecting wrists, fingers, neck, shoulders, elbows, hips, knees, ankles, and feet. These symptoms are associated with synovitis of joint and tendon sheaths, articular cartilage loss, and erosion of juxta-articular bone.⁴ The atlantoaxial joint is commonly affected in rheumatoid arthritis because of attenuation of the transverse ligament and erosion of the odontoid peg, which may cause instability of the cervical spine and rigidity of the neck with restricted extension or flexion. Severe osteoporosis also placed this patient in a very vulnerable condition. Patients with cricoarytenoid rheumatoid arthritis may present with a mass in the larynx, which can cause significant destruction of the surrounding structures. Laryngeal amyloidosis and rheumatoid nodules may also cause obstruction of the larynx. Temporomandibular involvement may limit mouth opening and render direct laryngoscopy impossible. Therefore, tracheal intubation difficulties in patients with rheumatoid arthritis are probably encountered during anesthesia management. Previous reports described that video-laryngoscope is a promising intubation device, which enables good visualization of the larynx and have the same or even a higher intubation success rate with less time, compared with direct laryngoscopy during difficult airway management.2, 5 Moreover, the video-laryngoscope had been one of suggested contents of a portable storage unit, and a combination of intubation methods might be recommended for difficult airway management according to the 2013 practice guidelines of the American Society of Anesthesiologists.⁶Therefore, in this case, we first used the GlideScope to implement tracheal intubation on the basis of preoperative airway assessment indicating the patient's moderate mouth opening (Mallampati Class II), although her neck was rigid and could not be extended backward. A video-laryngoscope contains miniature video cameras, enabling the operator to visualize the glottis indirectly. However, the blade of the GlideScope failed to lift the epiglottis for glottis exposure and the following repeated blind intubations were not successful, which imply that the extent of difficult airway was inconsistent with preoperative assessment and went beyond our original anticipation. The size of a direct laryngoscope is smaller than a video-laryngoscope and hence the former may lift the epiglottis more conveniently; however, the epiglottis may possibly remain invisible when a direct laryngoscope is used under the condition of limited neck activity and moderate mouth opening. Therefore, we did not try it. Although the GlideScope reveals the larynx more frequently than the conventional direct laryngoscope, it often proves difficult to advance the endotracheal tube toward the larynx and through the cords. Use of a stylet can often be of great help; however, this blind technique has a high failure rate and also introduces a risk of airway traumatic injury. Repeated attempts may increase the risks of hypoxemia, cardiovascular stress, and aspiration. Fortunately, mask oxygenation provided effective ventilation to keep oxygen saturation stable without using the prepared laryngeal mask. Then, we replaced the intubation device with a bronchofibroscope and inserted it through the nasal cavity. However, we still could not manipulate the tip of bronchofibroscope to reach the inlet of glottis for successful intubation. One possible reason is that during general anesthesia, the lumen of the pharynx usually becomes smaller as a result of reduced muscle tone. Another reason may be deformation of the pharynx structures caused by rheumatoid chronic inflammation.

Considering that neither the GlideScope nor the bronchofibroscope alone was able to complete intubation under general anesthesia, we attempted to combine the two devices to facilitate intubation because each has its advantage in terms of airway exposure. Insertion of the GlideScope helps lift the tongue and the jaw, opening up these structures, and facilitates the identification of anatomical landmarks by the operator of the bronchoscope. Meanwhile, the GlideScope can display the position of the tip of the bronchoscope. In addition, combination of both may be particularly valuable in averting lengthy detours to peripheral structures such as the piriform fossae. In our setting, the GlideScope facilitated progression of the bronchoscope toward the larynx by keeping the oropharynx open, as well as by enlarging the lumen of the pharynx to reduce erratic lateral advancement. Moreover, the operator who manipulated the bronchoscope could utilize the double-screen view, for a simultaneous vision of the bronchoscopic view of laryngeal structures and the position of the tip of the bronchoscope through the GlideScope (Fig. 1B). The control of the bronchoscope helps to reach and enter the larynx and may be particularly valuable with higher Cormack–Lehane grades as reported previously.⁶ The combination of both scopic techniques permits visual control of the passage of the tube over the bronchoscope into the laryngeal inlet and may help solve difficulties at this point. Clearly, two operators are required to manage such an anticipated difficult airway.

In this case (Fig. 1A), full airway evaluation including thyromental distance, length of neck, thickness of neck, and range of motion of head and neck should be performed prior to induction of anesthesia. Considering previous reports5, 7 and our experience described here, a combination of the GlideScope and a bronchoscope can be considered when unexpected difficult intubation occurs after respiratory deprivation in rheumatoid arthritis patients.

Acknowledgments

The authors thank Jing Liu at Southwest Hospital, Chongqing, China for her schematic drawing; this case study was supported only by departmental and hospital sources.