CASE PRESENTATION
A 49-year-old woman (144 cm; 60 kg) experienced spontaneous, upper leg
pain. She was bedridden with gradually worsening of dyspnea and finally
called an ambulance.
In early childhood the patient was diagnosed with severe juvenile
idiopathic arthritis. She had undergone multiple previous surgeries all
of which were performed with ATI-FB. At one occasion, after securing the
airway, inducing unconsciousness and neuromuscular relaxation, attempts
at introducing a HA-VL (McGrath-MAC X-BladeTM,
Medtronic, MN, USA) were unsuccessful due to severely limited mouth
opening.
In the emergency department the patient was diagnosed with a femoral
fracture and pneumonia (Fig. 1). She deteriorated and was transferred to
the intensive care unit. The respiratory rate was 40 breaths/min,
peripheral oxygen saturation was 88-95% (with 5 L/min oxygen delivered
via nasal cannula), heart rate was 120 beats/min, and blood pressure was
130/70 mmHg. Intermittently, the patient could still follow commands
(such as squeezing a hand), but no longer opened her eyes or responded
verbally. After Non-invasive Ventilation (NIV) on maximal settings, her
arterial gas showed pO2 at 8.2 kPa, pCO2 at 12.8 kPa, pH at 7.30,
lactate at 0.6 mmol/L, and base excess at 13.1 mmol/L. Airway
examination revealed a mouth opening of 13 mm, severely limited neck
movement (< 80º), severe retrognathia, and a short neck that
was difficult to palpate (Fig. 1).
The patient was positioned upright sitting and preoxygenated with NIV,
followed by high-flow nasal oxygen (HFNO) for the intubation itself.
Glycopyrrolate 0.2 mg (Meda, Solna, Sweden) was administered slowly
intravenously. The cricothyroid membrane was identified and marked.
Sedation was achieved with midazolam 0.25 mg (Hameln, Hameln, Germany)
and s-ketamine 5 mg (Pfizer, Ixelles, Belgium), which were both titrated
slowly and administered intravenously. For the sake of speed and
simplicity, lidocaine 2% with epinephrine 5µg/ml (Amgros, Copenhagen,
Denmark) was used for topicalisation supplemented with spray application
of lidocaine 10% (Xylocaine Pump Spray 100 mg/ml, AstraZeneca,
Södertälje, Sweden). Nebulisation on the NIV machine (5 ml ×2), spray
application (3 puffs ×2), transtracheal injection (2 ml ×1),
infiltration superficially to the cricothyroid membrane (3 ml ×1), nasal
atomising (MAD NasalTM, Teleflex, Waine, PA, USA), and
direct nasal application with a local anaesthetic soaked ribbon gauze (1
ml ×2 and 5 ml ×1, respectively) were applied. Intubation was then
performed with an FB (Ambu®aScope™ Regular, Ambu, Ballerup, Denmark), a
Portex®Soft Seal® tracheal tube with an internal diameter of 7.0 mm
(Smiths Medical, Minneapolis, MN, USA) and a size 8-cm Berman Intubating
Airway (Vital Signs, Totowa, NJ, USA), which maximally compressed could
just be inserted between the teeth. The flashing bright light from the
IRRIS momentarily allowed identification of the relevant structures.
During the procedure (see Supplemental Video S1), vital signs remained
stable including peripheral saturations at 85-95%. Total time from
initiation of topicalisation to successful intubation was 13 minutes,
whereas the intubation itself took less than 2 minutes. Visual
confirmation of tube placement, gentle cuff inflation and immediate
capnography were followed by propofol infusion and initiation of
mechanical ventilation.