Awake fiberoptic orotracheal intubation using a modified Guedel airway in a patient with craniocervical instability and an anticipated difficult airway: A case report

In patients with upper cervical instability, airway management may provoke subluxation of the craniocervical region and neurologic injury, and can be challenging for the anesthesiologist. Endotracheal intubation using a fiberoptic bronchoscope is frequently used in these patients to minimize spine motion, but this procedure may fail in patients with altered airway anatomy. When fiberoptic endotracheal intubation fails in these patients, optional intubation methods are limited. We describe successful awake fiberoptic orotracheal intubation using a modified Guedel airway divided in the midline for a 59-year-old man with an anticipated difficult airway, due to limited mouth opening, a nasopharyngeal tumor, and craniocervical spine instability after failure of conventional fiberoptic orotracheal intubation.

Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children.

BACKGROUND: Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process. MATERIALS AND METHODS: 30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place. RESULTS: Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15). CONCLUSION: In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.