Emergency tracheal intubation using a gum elastic bougie through a laryngeal mask airway

Emergency airway management often occurs out of hours when only less experienced staff are available and immediate access to equipment may be delayed. We wish to report such a case. A 74-year-old female with severe rheumatoid arthritis and acute left sided lobar pneumonia was referred to us for respiratory support. Airway assessment revealed a severe fixed flexion deformity of her neck, a receding mandible with a thyromental distance of 2 cm, an interincisor distance of 3 cm, and partial dentition. She was transferred to the intensive care unit (ICU) for awake fibreoptic intubation. However, as she was wheeled through the doors of the unit she suffered an asystolic cardiorespiratory arrest. Manual ventilation with 100% inspired oxygen via a facemask and oropharyngeal airway together with atropine 3 mg i.v. restored her cardiac output and heart rate. She remained unresponsive, however. Direct laryngoscopy proved difficult in view of her anatomical abnormality and she was found to be Cormack and Lehane grade 4 [1]. A size 3 classic laryngeal mask airway (LMATM, Intavent Orthofix, Maidenhead, UK) was inserted and ventilation improved marginally. As the fibreoptic laryngoscope was not yet available, a gum elastic bougie was passed blindly through the laryngeal mask airway and into the trachea, as confirmed by resistance to advancement at approximately 30 cm. The laryngeal mask airway was removed and a size 7.0 mm tracheal tube was railroaded over the bougie and controlled ventilation established. A lateral neck X-ray taken following intubation revealed the severity of her disease (Fig. 5). In view of the likelihood of prolonged ventilation and concerns over the consequences of accidental extubation, an early tracheostomy was performed by the ENT surgeons, with some technical difficulty, on day 2. Lateral neck X-ray postintubation showing the severity of the fixed flexion deformity. This case illustrates several points regarding difficult airway management. Firstly, there was a lack of appreciation of potential airway difficulties by non-anaesthetic staff. Clearly, this patient should have been referred before she was in extremis when a more controlled approach to airway management could have been employed. Second, difficult airway equipment including fibreoptic scope and airway adjuncts such as intubating laryngeal mask airways should be immediately available in ICU at all times. This is particularly important as the ‘awaken patient’ scenario proposed for ‘can’t intubate, can't ventilate (adequately)' elective theatre patients [2] is often not an option for patients referred to ICU. Intubation of the difficult elective airway by blindly passing a gum elastic bougie into the trachea via a regular laryngeal mask airway has been previously described [3]. Allison reported a success rate of 88% in elective cases [4] but subsequent studies have reported much lower success rates of 20–28%[5, 6]. As a result, it has been concluded that this technique is unreliable and not recommended as part of the failed intubation drill. Variable success rates for blind intubation 30–90% passing a tracheal tube via the classic laryngeal mask airway have also been reported [7–9]. It has been suggested that insertion of the intubating laryngeal mask airway may be easier than conventional laryngeal mask airway in patients with a fixed flexion deformity [10, 11]. The Difficult Airway Society guidelines suggest that fibreoptic brochoscopy via an intubating laryngeal mask airway and railroading of the tracheal tube followed by cricothyrotomy if unsuccessful, might have been the option of choice for our patient [2]. This is a technique that demands practice in elective cases prior to attempts in the emergency situation. Our decision to attempt blind bougie passage resulted from the gravity of the situation and the lack of other immediately available equipment. We recommend that, as the technique is simple and quick, it could still be considered in such cases while other emergency equipment is being prepared. However, it should not delay attempts at other techniques with potentially a higher success rate. The need for rehearsal of such difficult airway drills and the need to educate our non-anaesthetic colleagues cannot be overemphasised.

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