The Glidescope® for tracheal intubation in patients with ankylosing spondylitis
Ankara, Turkey
* E-mail: gunaydin{at}gazi.edu.tr
Editor—After reading the article on use of Glidescope® for tracheal intubation in patients with ankylosing spondylitis (AS),1 we had an opportunity of using this in a patient with AS with predicted difficult intubation on preoperative evaluation.
A 43-yr-old male patient (weight 40 kg and height 160 cm) with AS + rheumatoid arthritis was undergoing removal of infected hip prosthesis. His current preoperative airway assessment was: Mallampati classification III, thyromental distance 4 cm, inter-incisor gap 2 cm, and atlanto-occipital extension completely limited. We initially planned neuroaxial anaesthesia. Unfortunately, our attempts failed and the operation was cancelled. The next day, we prepared all the required equipment for difficult airway and intubation. In the operating theatre, heart rate, non-invasive blood pressure, and peripheral oxygen saturation were monitored. After an efficient preoxygenation, the patient received i.v. 1 µg kg–1 of fentanyl and 2 mg kg–1 of propofol. After full neuromuscular relaxation with 1.5 mg kg–1 of succinylcholine, Macintosh (Heine, Germany) laryngoscope with a size 3 blade was used for initial direct laryngoscopy. Laryngeal view was grade IV (Cormack Lehane) and the glottic opening was not viewed. For the second attempt, a McCoy laryngoscope was used, but also failed. Then we attempted to use the Glidescope®. As the cervical spine was totally immobile, neither extension nor flexion of the neck was possible, using Glidescope® was difficult and we could hardly place it in the mouth. Although we could not obtain a better laryngoscopic view, we blindly inserted an orotracheal tube, but it was not in the correct place and was removed. Meanwhile, the patient had started to breathe spontaneously. Fibre-optic intubation was attempted, but failed as nasal route was not patent. The patient then received additional propofol for placing an alternative airway device. Initially, combitube was placed, but peripheral oxygen saturation started to decline and this was replaced by an LMA Fastrack. The patient was ventilated with 50% oxygen–air mixture in approximately 1–1.5% sevoflurane and remifentanil infusion of 0.2 µg kg–1 min–1 was added. Infected hip protesis was removed in 30 min by surgeons.
Anaesthesia for patients with AS as neuraxial blocks may be difficult and general anaesthesia is then required.2 It has been reported that Glidescope® improved better laryngeal view and provided better glottic exposure in patients with simulated difficult airway and in patients requiring general anesthesia for elective surgery without difficult airway.3 4 In contrast, we were unable to intubate using the Glidescope®. Lai and colleagues1 successfully performed nasotracheal intubation using the Glidescope® in 8 of 11 difficult laryngoscopy patients with AS. As our patient's nasal route was not patent, we cannot comment on this approach. In patients with severe AS, a difficult airway and insufficient nasal access still remain problematic.
References
1 Lai HY, Chen IH, Hwang FY, Lee Y. (2006) The use of the Glidescope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 97:419–22.
2 Ahmad N, Channa AB, Mansoor A, Hussain A. (2005) Management of difficult intubation in a patient with ankylosing spondylitis—a case report. Middle East J Anaesthesiol 18:379–84.[Medline]
3 Lim Y and Yeo SW. (2005) A comparison of the Glidescope with the Macintosh laryngoscope for tracheal intubation in patients with simulated difficult airway. Anaesth Intensive Care 32:243–7.
4 Hsiao WT, Lin YH, Wu HS, Chen CL. (2005) Does a new videolaryngoscope (glidescope) provide better glottic exposure? Acta Anaesthesiol Taiwan 43:147–51.[Medline]
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