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Table of Contents  
LETTER TO EDITOR
Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 533-534  

Airway management with videolaryngoscope in a morbidly obese patient in a tertiary care centre: Are the peripheral hospitals ready for such a scenario?


Departments of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS Asvini, Colaba, Mumbai, Maharashtra, India

Date of Web Publication16-May-2017

Correspondence Address:
Deepak Dwivedi
Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS ASVINI, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_25_17

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How to cite this article:
Dwivedi D, Bhatnagar V, Tandon U, Kumar P. Airway management with videolaryngoscope in a morbidly obese patient in a tertiary care centre: Are the peripheral hospitals ready for such a scenario?. Anesth Essays Res 2017;11:533-4

How to cite this URL:
Dwivedi D, Bhatnagar V, Tandon U, Kumar P. Airway management with videolaryngoscope in a morbidly obese patient in a tertiary care centre: Are the peripheral hospitals ready for such a scenario?. Anesth Essays Res [serial online] 2017 [cited 2020 Jul 14];11:533-4. Available from: http://www.aeronline.org/text.asp?2017/11/2/533/205227

Sir,

Difficult Airway management is definitely a nightmare, especially when attempted during the emergency settings when the resources are limited. It further gets compounded in the presence of morbidly obese patients with the limited respiratory reserve presenting for an emergency surgery requiring general anesthesia.[1],[2]

Evidence is enough to show that with the dawn of the era of videolaryngoscope (VLS), the incidence of failed intubation in patients with anticipated difficult airway is fewer.[3] VLS as an alternative to direct laryngoscopy has proved to be path breaking in airway management.[4] Fiberoptic awake intubation as considered a standard requires time to acquire the skill and the equipment is costly.

We present a 75-year-old lady, weighing 125 kg with body mass index of 52 presented with suspected obstructed umbilical hernia for emergency surgery. She was a known case of obstructive sleep apnea and chronic obstructive pulmonary disease on home bilevel positive airway pressure therapy. Other comorbidities included diabetes, hypothyroidism, and depression. Airway examination revealed normal mouth opening with Mallampati Class IV, neck circumference of 45 cm, neck movements restricted, all pointing toward difficult airway [Figure 1].
Figure 1: Morbidly obese patient intubated in a ramped-up position

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General anesthesia with awake intubation was planned. Preoperatively, antisialogogue was administered. Intubating laryngeal mask airway and fiberoptic bronchoscope were kept as a standby. After attaining the airway blocks, the patient was shifted to operation theater, padded well at pressure points, and placed in a ramped-up position. Adequacy of mask ventilation checked followed by preoxygenation with 100% oxygen for 4 min. Check videolaryngoscopy with Kingvision channeled laryngoscope with size three blade was performed by an anesthesia trainee on call under supervision, which revealed Cormack-Lehane Grade III. VLS was tolerated well. The patient intubated with size 7.5 mm endotracheal tube in one attempt with minimal hemodynamic response.

Incidence of difficulty to intubate in obese patient can be as high as 11% with 6% patients difficult to mask ventilate.[5] As our institute being a tertiary care center with the anticipated difficult airway, we were better prepared. Difficult airway adjuncts with fiberoptic bronchoscope were kept as our Plan B; however, VLS was utilized by a trained resident as a Plan A with success in securing the airway in the first attempt.

Scenario is different in constraint environment such as peripheral hospitals and primary health centers where unanticipated emergency airway management is a daunting task. In such places with very limited resources and unavailability of the skilled anesthesiologist, the situation becomes very challenging. VLS can play a vital role as rescue devices in the absence of fiberoptic equipment for managing difficult airways of patients unfit for transfer to higher referral centers.

Use of VLS can be translated into other emergency situations where airway management is required by less-skilled personnel such as paramedics in trauma and field emergency situations.

Recent Cochrane review by Lewis et al. comparing VLS with direct laryngoscopy where 64 studies were enrolled with 7044 participants could find only two studies which recruited the obese patients. The review stressed about the success of VLS in difficult airway situations.[3]

Therefore, more studies need to be conducted for larger usage of VLS for utilization of securing airway by the paramedics and residents. To conclude, VLS as a tool can be exposed to a larger population as in peripheral, smaller medical setups. Wider availability of VLS in such settings can prove to be a boon to the caregivers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kristensen MS. Airway management and morbid obesity. Eur J Anaesthesiol 2010;27:923-7.  Back to cited text no. 1
[PUBMED]    
2.
Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol 2014;80:382-92.  Back to cited text no. 2
    
3.
Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev 2016;11:CD011136.  Back to cited text no. 3
[PUBMED]    
4.
Moore AR, Schricker T, Court O. Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese. Anaesthesia 2012;67:232-5.  Back to cited text no. 4
[PUBMED]    
5.
Shailaja S, Nichelle SM, Shetty AK, Hegde BR. Comparing ease of intubation in obese and lean patients using intubation difficulty scale. Anesth Essays Res 2014;8:168-74.  Back to cited text no. 5
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