Topicalisation of airway for awake fibre-optic intubation: Walking on thin ice

Abstract

Topicalisation of the airway by various techniques has routinely been recommended for awake fibre-optic bronchoscopy in cases of difficult airway. However, topicalisation by itself can cause airway obstruction by decreasing the tone of the laryngeal muscles and causing a dynamic air inflow obstruction. Two cases of difficult airway are illustrated where anaesthetising upper airway with nebulisation with 4% lignocaine (Xylocaine™) or 2% lignocaine (Xylocaine™) jelly resulted in stridor and upper airway obstruction. This is the first reported case of airway obstruction after lignocaine (Xylocaine™) jelly. We would like to highlight that topicalisation of airway, once thought as a relatively safe technique, can cause airway collapse if not detected and anticipated at the earliest. Pre-operative spirometry and airway ultrasonography can be useful in detecting the patients at risk of developing airway obstruction. Using a nasopharyngeal airway during topicalisation can serve as a valuable device in preventing total airway obstruction in susceptible patients.

Management of a case of anticipated difficult airway in a patient with Moebius syndrome

“…The airway was anaesthetised by 2 ml 2% lignocaine with adrenaline soaked nasal pledgets, 4 puffs 10% lignocaine spray of the throat, and 4 ml of 2% lignocaine to block superior laryngeal nerve and transcricoid injection. [ 2 ] After piercing the cricothyroid membrane with an 18G Tuohy needle, a 0.035 floppy tip Terumo guidewire (Biorad Company) with a smooth flexible tip on one end, was introduced. [ 3 ] Guidewire was advanced gently and when it appeared in the mouth, was taken out through the nose with the help of a Ryle's tube inserted nasally.…”