Published online Aug 16, 2021. doi: 10.12998/wjcc.v9.i23.6705
Peer-review started: January 7, 2021
First decision: February 12, 2021
Revised: February 21, 2021
Accepted: April 20, 2021
Article in press: April 20, 2021
Published online: August 16, 2021
Severe kyphosis is common in late stage of ankylosing spondylitis (AS), and tracheal intubation, especially one-lung ventilation, is particularly difficult. Such patients are rare, and have a predictable difficult airway. Awake fiberoptic intubation is the safest choice. Compared with double lumen bronchial catheter, the use of bronchial blocker for one-lung ventilation is particularly suitable for such patients. It is a great challenge for anesthesiologists to choose sedative drugs and methods to complete awake fiberoptic intubation while ensuring oxygenation.
Twelve cases of AS with spinal deformity were analyzed retrospectively to summarize the drug selection, appropriate dose, and patient tolerance of awake fiberoptic intubation, so as to provide guidance for clinical predictable awake fiberoptic intubation and one-lung ventilation in difficult airway.
To summarize the drug selection, appropriate dose, and patient tolerance of awake fiberoptic intubation.
The electronic case records were used to collect the general information of patients. Preoperative airway assessment of difficult airway (including Wilson's score, Mallampati classification, thermomental distance, interval gap, neck mobility, etc.) was performed. Appropriate doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl and midazolam were given before intubation, and the nasal cavity was treated with a lidocaine and ephedrine cotton swab. The preparation time before tracheal intubation, intubation time, facial expression score, airway responsiveness score when fiberoptic bronchoscope was introduced, and airway responsiveness score when tracheal intubation entered the nostril were recorded. Lung collapse and surgical field score was recorded. Blood pressure and heart rate were recorded at different time points. The patients were followed for nasal bleeding, sore throat, hoarseness, dysphagia, etc.
Among the 12 patients, 11 were male and 1 was female; the history of AS was 20.4 ± 9.6 years, the Willson's scores were 5 or above, Mallampati tests were grade III or IV, the inter-incisor distance was 2.9 ± 0.3 cm, and the thyromental distance was 4.8 ± 0.7 cm. The preparation time before intubation was 20.4 ± 3.4 min, and the intubation time was 2.6 ± 0.4 min. The facial grimace score was 1.7 ± 0.7, the airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score were 1.2 ± 0.4. The SBP, DBP, and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). While the values at T1 were not significantly different from those at T2-T4 (P > 0.05), they were significantly different from those at T5 (P< 0.05). Seven patients had minor epistaxis during endotracheal intubation, two were followed 24 h after surgery with mild sore throat, and two had hoarseness without dysphagia.
Ankylose spondylitis patients with severe cervical and thoracic kyphosis should be intubated by fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Before intubation, proper dosage of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, can provide satisfactory tracheal intubation conditions while maintaining the comfort and safety of patients. Bronchial blocker is safe and effective for one-lung ventilation in such patients during thoracotomy.
The Tampa bronchial blocker used in adults can pass through the endotracheal tube with the minimum inner diameter of 7.0, which leads to a larger inner diameter of the endotracheal tube selected for nasal intubation and higher incidence of epistaxis. The comfort of individual patients during intubation is slightly poor, so it is necessary to further explore the individualized use of sedative drugs. How to choose a more reasonable ventilation mode for patients with special difficult airway needs to be further explored.