Kenneth Moran, MD
Vice Chair of Education
Andrew Roth, MD
Department of Anesthesiology
The Ohio State University Wexner Medical Center
Adam Dalia, MD, MBA
CardioThoracic Anesthesiology Fellow
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Awake nasal fiber-optic intubation (FOI) is performed when a patient’s airway is compromised and an oral route either has failed or is deemed unsafe to perform. This case presents the use of a modified nasal trumpet for the management of an unusual complication during nasal FOI in a patient with angioedema, weighing 107 kg.
The removal of the modified nasal trumpet caused a circumferential tear that resulted in a 1-cm ring of rubber left around the tip of the endotracheal tube (ETT) after a tenuous nasal FOI. A literature review found varying techniques and equipment used in nasal FOI, but none offered insight on managing complications with nasal trumpet equipment failure. This report describes a difficult airway caused by angioedema, failure of a modified nasal trumpet, and the actions taken to remedy the problem.
An 82-year-old man with a history of myocardial infarction and chronic obstructive pulmonary disease presented to the emergency department with angioedema and dyspnea. He had undergone a partial right glossectomy and neck dissection 1.5 years ago. His wife reported spontaneous tongue swelling over the preceding three to four hours, and noted that he was a “difficult intubation.”
On examination, the patient’s tongue appeared swollen, edematous, firm, and scarred. He was unable to retract his tongue. After an unsuccessful attempt to perform an awake oral FOI, an awake nasal FOI was tried. A nasal trumpet was cut longitudinally from the top, leaving less than 1 cm of the tip intact (Figure 1). This technique was used to facilitate advancement of the fiber-optic scope (FOS) and eventual removal of the trumpet from around the scope in order to guide an ETT through the nasal passage.
The nasal trumpet was used to introduce the scope into the nasopharyngeal space, and the scope was passed successfully into the trachea just as the patient’s respiratory status began to decompensate. Unfortunately, while removing the nasal trumpet from around the FOS, instead of extending the longitudinal cut through the intact tip, it tore horizontally within the nasopharynx. This left a small portion of the trumpet circumferentially attached around the FOS (Figure 3). Faced with a decompensating patient, a decision was made to advance the tube over the FOS despite the foreign body remaining wrapped distally around the scope. After confirmation of end-tidal carbon dioxide, the patient was sedated and oxygen saturations remained stable.
Placement of the FOS into the ETT revealed that the piece of nasal trumpet was visible through the wall of the ETT. The detached last centimeter of the nasal trumpet had become wrapped circumferentially around the distal end of the tube. Since the trumpet appeared to be firmly wrapped, the patient was adequately preoxygenated and a tube exchanger was used in an attempt to remove the ETT and trumpet piece simultaneously. To our disappointment, the nasal trumpet was no longer at the tip of the ETT; it remained wrapped around the ETT exchanger. We used a MAC blade to retract the tongue and visualize the posterior pharynx for the trumpet piece before attempting to pass a new ETT. The swollen tissue did not permit visualization beyond the base of the tongue. However, we were able to feel the tube exchanger and the edge of the trumpet piece using our fingers. Since the piece was intact circumferentially around the tube exchanger, we used forceps to pull the trumpet piece into the pharynx and then scissors to cut it off the tube exchanger.
A new number 7 ETT was successfully advanced back into the airway over the ETT exchanger. Fortunately, the patient maintained adequate oxygen saturations throughout the entire procedure. The patient remained intubated and was transferred to the ICU. The angioedema resolved adequately enough after 36 hours to allow successful extubation without complications.
This case serves as a valuable lesson about the possibility of complications when using equipment in a modified or novel manner. Although this technique had been used for many years at our institution, it is not well studied. In this particular case, the nasal trumpet should have been cut down its entire length, or at least down to within 1 mm of its tip, to facilitate placement while reducing the risk for a circumferential tear. Leaving more than 1 mm of intact circumference at the tip of the nasal trumpet allowed for a transverse tear and incomplete removal of the nasal trumpet from around the FOS before advancing the ETT. This case also emphasizes the importance of using problem-solving skills when faced with unique complications or outcomes. We were unable to find any literature that specifically addresses this particular use of nasal trumpets during nasal FOI. However, the literature does demonstrate that using equipment to guide an FOS into the nasopharynx is superior to unaided nasal insertion using only an FOS with an ETT.1 Nonetheless, this particular complication could have been avoided if modification of the nasal trumpet had not occurred.
Mohammadzadeh M, Haghighi M, Naderi B, et al. Comparison of two different methods of fiber-optic nasal intubation: conventional method versus facilitated method (NASAL-18). Ups J Med Sci. 2011;116(2):138-141.