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Brief Communication
REFERENCES
1. Rulli F, Ambrogi V, Dionigi G, Amirhassankhani S, Mineo TC,
Ottaviani F, et al. Meta‑analysis of recurrent laryngeal nerve
injury in thyroid surgery with or without intraoperative nerve
monitoring. Acta Otorhinolaryngol Ital 2014;34:223‑9.
2. Flukes S, Ling S, Leahy T, Sader C. Intraoperative nerve
monitoring in otolaryngology: A survey of clinical practice
patterns. Int J Otolaryngol Head Neck Surg 2013;2:21‑6.
3. Calò PG, Pisano G, Medas F, Pittau MR, Gordini L,
Demontis R, et al. Identification alone versus intraoperative
neuromonitoring of the recurrent laryngeal nerve during
thyroid surgery: Experience of 2034 consecutive patients.
J Otolaryngol Head Neck Surg 2014;43:16.
4. Randolph GW, Kamani D. Intraoperative electrophysiologic
monitoring of the recurrent laryngeal nerve during thyroid
and parathyroid surgery: Experience with 1,381 nerves at risk.
Laryngoscope 2017;127:280‑6.
5. Sari S, Erbil Y, Sümer A, Agcaoglu O, Bayraktar A, Issever H,
et al. Evaluation of recurrent laryngeal nerve monitoring in
thyroid surgery. Int J Surg 2010;8:474‑8.
6. Barczynski M, Konturek A, Cichon S. Randomized clinical trial
of visualization versus neuromonitoring of recurrent laryngeal
nerves during thyroidectomy. Br J Surg 2009;96:240‑6.
7. Vasileiadis I, Karatzas T, Charitoudis G, Karakostas E,
Tseleni‑Balafouta S, Kouraklis G. Association of intraoperative
neuromonitoring with reduced recurrent laryngeal nerve
injury in patients undergoing total thyroidectomy. JAMA
Otolaryngol Head Neck Surg 2016;142:994‑1001.
8. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring
in thyroid surgery: Prospective evaluation of intraoperative
electrophysiological responses for the prediction of recurrent
laryngeal nerve injury. Ann Surg 2004;240:9‑17.
Airway trauma during difficult
intubation… from the frying pan
into the fire?
INTRODUCTION
Endotracheal tube (ETT) introducers (commonly
known as bougies) help the anaesthesiologist in
securing the airway during an unanticipated difficult
intubation. Traumatic complications with bougies are
rare but serious complications. We report a case of an
unanticipated difficult intubation, where the bougie,
used to secure the airway, led to bronchial injury.
CASE REPORT
A 46‑year‑old male, with no preexisting lung or heart
ailments, diagnosed with severe cervical myelopathy,
was posted for anterior cervical corpectomy and
fusion. Apart from his echocardiogram, which showed
mild pulmonary artery hypertension (right ventricular
systolic pressure = 43 mmHg) associated with mild
mitral stenosis (mitral valve area = 2 cm2) and mitral
Indian Journal of Anaesthesia | Volume 61 | Issue 5 | May 2017
Page no. 79
9. Hemmerling TM, Schmidt J, Bosert C, Jacobi KE, Klein P.
Intraoperative monitoring of the recurrent laryngeal nerve in
151 consecutive patients undergoing thyroid surgery. Anesth
Analg 2001;93:396‑9.
10. Rajan S, Puthenveettil N, Paul J. Transtracheal lidocaine:
An alternative to intraoperative propofol infusion when
muscle relaxants are not used. J Anaesthesiol Clin Pharmacol
2014;30:199‑202.
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DOI:
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How to cite this article: Dixit H, Kamat L, Potdar M, Modi T. Role
of electromyography endotracheal tube in preventing recurrent
laryngeal nerve injury during thyroid surgery: A case report. Indian
J Anaesth 2017;61:435-7.
regurgitation, all other investigations were normal.
His airway examination revealed modified Mallampati
class III. Neck mobility was not assessed because of
his disc prolapse.
Anaesthesia was induced with intravenous (I.V.)
injection fentanyl (2 µg/kg) and injection propofol
(2 mg/kg), and injection atracurium (0.5 mg/kg) was
given after confirming mask ventilation. Laryngoscopy,
with minimal neck extension, revealed Cormack-Lehane
grade 3a view of the vocal cords with external laryngeal
manipulation. Portex™ single use 15 Fr 700 mm coude
tip bougie was first introduced up to 25 cm mark,
without eliciting tracheal click or hold up signs. Portex™
ETT size 8 mm I.D. was railroaded over the bougie
without much difficulty and the ETT cuff inflated. On
removal of the bougie, the tip was blood stained. There
was a gush of blood from the ETT. Suctioning was
done through the ETT, and its position was checked.
Ventilation was not achieved, and auscultation did
not reveal bilateral air entry and end‑tidal CO2 could
not be recorded, as there was blood in the sampling
line. Repeat suctioning through the ETT was done
and auscultation again did not reveal air entry. Since
the oxygen saturation started dropping to 80% and
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Brief Communication
the position of ETT could not be confirmed, the ETT
was removed and the patient was ventilated with a
face‑mask. Mask ventilation was difficult and a classic
laryngeal mask airway size 4 was inserted. There was
no chest rise, and auscultation revealed no air entry
and SpO2 dropped further to 60%. Repeat laryngoscopy
was attempted, and airway was secured with Portex™
8 mm I.D. ETT with the help of the Portex™ bougie
again. No injury was visualised in the oral cavity and
supraglottic area during laryngoscopy. There was still
blood inside the ETT, but with repeat suctioning and
lavage with dilute epinephrine (1:100,000) the bleeding
was controlled. Injection tranexamic acid 1 g and
injection dexamethasone 8 mg I.V. were administered.
Auscultation revealed extensive wheeze and the peak
airway pressure was 45 cm H2O and SpO2 increased to
95%.
An emergency bronchoscopy revealed bleeding
from the right main bronchus. After instillation of
topical tranexamic acid and repeated lavage, the
bleeding was localised to be from the right middle
bronchus [Figure 1]. The bleeding was controlled
eventually. No definitive injuries could be visualised
anywhere along the tracheobronchial tree while
withdrawing the ETT till the vocal cords over
the fibreoptic bronchoscope. Since the ventilator
parameters were satisfactory after bronchoscopy, it
was decided to proceed with posterior decompressive
laminectomy in the prone position. The decision was
taken considering the possibility of rebleed during
surgery and better drainage of the blood through ETT
in the prone position. The rest of the intraoperative
course was uneventful. After surgery, the patient was
turned supine, neuromuscular blockade was reversed
and trachea extubated. Postoperatively, the SpO2
Figure 1: Fibreoptic bronchoscopic view of the bronchial tree showing
bleeding from the right middle bronchus
438
Page no. 80
maintained above 95% with 6 L/min oxygen flow
through a facemask.
Computed tomogram of the chest done after 6 h
showed patchy consolidation and centriacinar
nodules in lateral segment of the right middle lobe
and extensive centriacinar airspace opacities in both
lungs– suggestive of aspiration changes [Figure 2]. The
bronchial lavage fluid was normal. The patient had an
uneventful recovery.
DISCUSSION
Traumatic complications during unanticipated difficult
intubation range from 0.5% to 7%.[1] Bougies are used
to facilitate tracheal intubation for Cormack‑Lehane
grades of 2b or 3a during laryngoscopy. However,
All India Difficult Airway Association does not
recommend blind insertion of bougies in Grade 3b or
4 direct laryngoscopic view as it can lead to trauma.[2]
However, the reports of airway trauma due to bougies,
are limited to only a few case reports, and the incidence
of bronchial injury even fewer.[3,4] Trauma was more
often with single use bougies.[5] The coude tip of the
bougie was designed to facilitate easy passage into
the laryngeal inlet, and to prevent it from going too
far down the airway, thereby reducing traumatic
complications.[6] However, in our case, the coude tip
did not prevent the bougie from causing injury.
Trauma related to ETT bougies is suspected when
the bougie tip is stained with blood on withdrawal
and a gush of blood is observed through ETT. The
anaesthesiologist is presented with a triad of problems
at this stage – haemorrhage below the vocal cords,
inability to confirm ETT placement along with difficult
Figure 2: Computed tomogram of the chest showing patchy
consolidation and centriacinar nodules in the right middle lobe of the lung
Indian Journal of Anaesthesia | Volume 61 | Issue 5 | May 2017
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Brief Communication
intubation and inability to oxygenate. Infraglottic
airway injury in a difficult intubation is a rare and
life‑threatening incident and has no definitive airway
management guidelines in literature.
The placement of a bougie into the trachea has been
traditionally confirmed by the “tracheal click” sign or
the “distal hold up” sign. The “distal hold up” sign has
been shown to have more incidence of trauma even
with force as low as 0.9N.[7] In our case, even though
we did not elicit “distal hold up” sign, the bronchial
haemorrhage could have been due to the inadvertent
advancement of the bougie during railroading.
Railroading ETT under direct laryngoscopy guidance
to minimise the force, withdrawing the bougie 2–3 cm
before railroading the ETT, not advancing the bougie
more than 25 cm in average‑built adults can minimise
trauma due to bougies. In stressful conditions like an
unanticipated difficult intubation, the use of traffic‑light
bougie can prevent such dangerous practice of inserting
bougies too far, by rapidly assessing the depth inserted
with the help of the three colours on it.[8]
In all reported cases of airway trauma due to bougies,
conservative management with endotracheal
suctioning is mentioned. Endobronchial instillation
[3,4]
of tranexamic acid (500 mg in 20 ml) can be as
efficient as epinephrine (1 mg in 20 ml) in controlling
haemoptysis and requires less frequent use of
the second medicine.[9] Fibreoptic endobronchial
epinephrine instillation is an effective, rapidly feasible
and beneficial therapy for life‑threatening haemoptysis
in intubated and mechanically ventilated patients.[10]
CONCLUSION
Until definitive recommendations are in place for an
infraglottic airway bleed during difficult intubation,
we believe that airway injury by a bougie can be
prevented by avoiding hold up sign, gentle and careful
insertion of the bougie. Railroading of ETT over the
bougie under direct laryngoscope guidance, use of a
traffic signal bougie, avoiding bougies with metal core
and obtaining help from an assistant to stabilise the
bougie to prevent it from moving inwards are other
approaches.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Indian Journal of Anaesthesia | Volume 61 | Issue 5 | May 2017
Page no. 81
Sriraam Kalingarayar, Amar Nandhakumar,
Santhakumar Subramanian1, Sreedharan Namboothiri2
Departments of Anaesthesiology, 1Pulmonology and 2Orthopaedics,
Kovai Medical Center and Hospitals, Coimbatore, Tamil Nadu, India
Address for correspondence:
Dr. Sriraam Kalingarayar,
Department of Anaesthesiology, Kovai Medical Center and Hospitals,
Post Box No: 3209, Avinashi Road, Coimbatore ‑ 641 014,
Tamil Nadu, India.
E‑mail: sriraamk9380@gmail.com
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3. Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P,
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4. Arndt GA, Cambray AJ, Tomasson J. Intubation bougie
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5. Hodzovic I, Latto IP, Henderson JJ. Bougie trauma – What
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6. Hodzovic I, Wilkes AR, Latto IP. To shape or not to shape…
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Anaesthesia 2003;58:792‑7.
7. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie‑related
airway trauma: Dangers of the hold‑up sign. Anaesthesia
2014;69:219‑23.
8. Paul A, Gibson AA, Robinson OD, Koch J. The traffic light
bougie: A study of a novel safety modification. Anaesthesia
2014;69:214‑8.
9. Fekri MS, Hashemi‑Bajgani SM, Shafahi A, Zarshenas R.
Comparing adrenaline with tranexamic acid to control acute
endobronchial bleeding: A randomized controlled trial. Iran J
Med Sci 2017;42:129‑35.
10. Düpree HJ, Lewejohann JC, Gleiss J, Muhl E, Bruch HP.
Fiberoptic bronchoscopy of intubated patients with
life‑threatening hemoptysis. World J Surg 2001;25:104‑7.
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Access this article online
Quick response code
Website:
www.ijaweb.org
DOI:
10.4103/ija.IJA_140_17
How to cite this article: Kalingarayar S, Nandhakumar A,
Subramanian S, Namboothiri S. Airway trauma during difficult
intubation… from the frying pan into the fire?. Indian J Anaesth
2017;61:437-9.
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