A morbidly obese patient was emergently nasotracheally intubated using a fiberoptic bronchoscope Simultaneous application of 20 cm [Hsub2]O nasal continuous positive airway influence (CPAP) to the contralateral naris using a nasal pillow helped maintain ventilation of the patient during intubation and greatly facilitated visualization of anatomic landmarks and translaryngeal passage of the bronchoscope Fiberoptic video images of this patient's hypopharynx demonstrate the pharyngeal splinting action of nasal CPAP thus applied.
A morbidly obese patient was emergently nasotracheally intubated using a fiberoptic bronchoscope Simultaneous application of 20 cm [Hsub2]O nasal continuous positive airway influence (CPAP) to the contralateral naris using a nasal pillow helped maintain ventilation of the patient during intubation and greatly facilitated visualization of anatomic landmarks and translaryngeal passage of the bronchoscope Fiberoptic video images of this patient's hypopharynx demonstrate the pharyngeal splinting action of nasal CPAP thus applied. This is a novel approach to difficult intubation of the obese patient.
(Chest 1994; 106:287-88)
CPAP = continuous positive airway pressure; UA = upper airway
Emergent intubation of morbidly obese patients is frequently a very difficult procedure, plane for the most experienced intubator. Jaw mobility and neck flexion are repeatedly severely limited, making visualization of the vocal cords and passage of the endotracheal tube sometimes impossible.(1) steady fiberoptic intubation can be made difficult by means of the presence of redundant supraglottic mucosal tissue which hinders visualization of the vocal cords. We report herein a case in which emergent fiberoptic nasal intubation was facilitated from the simultaneous use of nasal continuous positive airway constraining force (CPAP) applied to the contralateral naris.
CASE REPORT
A 393-kg man was transported to the urgency Department of Charity Hospital of Louisiana with a 1-month history of progressive weight gain and shortness of breath and a 1-day history of altered mentation. Remarkable findings were as follows: brawny edema involving the face, neck stock abdomen, and extremities and occlusive apneas associated with oxyhemoglobin saturations ([SaO.sub.2]) as grave as 19 percent. The working clinical diagnosis was pickwickian syndrome with abysmal cor pulmonale. CPAP at 20 cm [Hsub2]O with [Flosub2] of 04 was initiated utilizing large-sized nasal pillows (Adam Nasal Pillows, Puritan Bennett, Lawrenceville, Ga), which are fine silicon nasal prongs that form an occlusive seal within each naris. The patient's [SaO.sub.2] improved to 50 percent however he remained unresponsive and the decision to intubate was made. Poor neck mobility, an interincisor distance of no other than 2 cm, and macroglossia interrupted successful direct laryngoscopy. Inability to palpate the tracheal cartilage preclud consideration of crisis cricothyroidotomy or retrograde intubation. Pseudoephedrine, 05 percent was instilled into the one and the other nares followed by 4 percent lidocaine jelly into the right naris in preparation for nasotracheal intubation. Blind nasotracheal intubation was not attempted for fear that interruption of the CPAP would be required to adequately auscultate breath heartys at the end of the tube. Instead, a lubricated 8-mm endotracheal tube was placed across a 7-mm fiberoptic bronchoscope which was then introduced into the right naris and rapidly advanced into the hypopharynx. During the intubation attempt, CPAP was continued via the contralateral naris in order to deliver oxygen and to facilitate ventilation. This was easily accomplished by dint of having an assistant occlude undivided pillow with an index finger while holding the other pillow comfortably into the left naris. This patient's [SaO.sub.2] was unaffected through the switch from bilateral to unilateral application of nasal CPAP. Simultaneous application of 20 cm [Hsub2]O CPAP to the contralateral naris permitted continuous visualization of the hypopharyngeal and laryngeal landmarks during the pair inspiration and expiration, and facilitated prosperous rapid, translaryngeal intubation.
His condition rapidly stabilized with mechanical ventilation and through the next 4 weeks he dissipated more than 90 kg of exces carcass water as his cor pulmonale improved. Photographs, obtained with this patient's permission during gastric bypass surgery 8 weeks after his emergent intubation, illustrate the splinting consequences on his hypopharynx of 20 cm [Hsub2]O CPAP applied to the left naris utilizing nasal pillows as described above (Fig 1) The photographs were obtained utilizing a 7-Fr fiberoptic bronchoscope inserted [i]or[/i] part of to the other the right naris. Six month after presentation, this patient's carcass weight was down to 205 kg
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DISCUSSION
Fiberoptic intubation may be performed with the patient in a supine or sitting position. The sitting position may be preferr as this position may shape respiratory distress and help separate the tongue from the posterior pharyngeal wall.(2)(3) The patient should be in cervical and atlanto-occipital extension if feasible. The "sniffing" position of cervical flexion and atlanto-occipital extension, while optimum for standard laryngoscopic intubations, increases obstruction of the glottis at the epiglottis during bronchoscopic intubation.(4) Having the patient pant or phonate, using a Macintosh blade upon a laryngoscope to lift the tongue, or manually pulling the tongue forward may also facilitate translaryngeal passage of the fiberoptic vent When attempting to pass the endotracheal tube throughout the bronchoscope and through the vocal cords, adequate local anesthesia and lubrication are vital. If resistance is met increasing lubrication and rotating the endotracheal tube 15[degrees] may facilitate readvancement.(3)
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