a rare potentially hazardous malposition of the nasotracheal tube

Indian Journal of Anaesthesia | Vol.. 56| Issue 4 | Jul-Aug 2012 434 Letters to Editor A rare, potentially hazardous malposition of the nasotracheal tube Sir, I read with interest the

Indian Journal of Anaesthesia | Vol 56| Issue 4 | Jul-Aug 2012 434

Letters to Editor

A rare, potentially hazardous

malposition of the nasotracheal

tube

Sir,

I read with interest the brief communication, “A

rare potentially hazardous malposition of the

nasotracheal tube” by Murali Chakravarthy.[1] I

appreciate the authors’ concerns regarding the

emphasis of following of standard procedure to avoid

errors during fibreoptic bronchoscopy (FOB)-aided

intubation However, I am not totally convinced with

the author’s way of dealing with this particular case

And I have the following points of disagreement and

dissatisfaction:

1 Why had regional anaesthesia not been chosen

for this patient – it is not mentioned by the

author anywhere that regional anaesthesia

should have been the first choice of anaesthesia

for right hiparthroplasty, in this patient looking

for the following points narrated by author:

a) Severely obese patient [? Body mass index

(BMI) not known]

b) H/O obstructuve sleep apnoea (OSA) single

5 years

c) H/O chronic smoking [suggestive of

possibility of chronic obstructive

pulmonary disease (COPD)]

d) Mallampatti Class 3

e) Short neck and limited neck mobility

f) Severely deviated nasal septum

Experts mention that, when feasible, regional

anaesthesia (RA) using a catheter to provide

continuous anaesthesia is useful in patients

with OSA.[2] Moreover, regional analgesia is

associated with a low incidence of apnoea and

periods of arterial hypoxaemia, making this

approach an attractive technique for providing

post-operative analgesia in such a patient.[2]

2 The authors have mentioned that as the patient

seemed uncomfortable because of the presence

of endotracheal tube (ETT), general anaesthesia

(GA) was induced, but there is no mention

of what was the SPO2 during that time? Also,

whether restlessness of the patient was just due

to ETT/gradual development of hypoxaemia/

lignocaine toxicity (from repeated topical

spray) In case of a really difficult intubation,

wherein we are planning for an awake FOB-aided ET intubation, induction of full-fledge GA with use of a non-depolarizing muscle relaxant

at the very first instance does not seem to be

“Standardized Guidelines” in any institute

in the Indian scenario Also, if you as a team had decided to induce him, then also the best choice would have been to take the patient deep into sevoflurane anaesthesia only with spontaneous ventilation because awakening of the obese patient is prompter after exposure

to sevoflurane than after administration of even Propofol.[3] Moreover, we all know that neuromuscular blocking drugs, characterized

by rapid spontaneous recovery, are most often selected in such group of patients.[3] Needless

to emphasize, when a muscle relaxant is to

be employed in a difficult/potentially difficult airway, succinylcholine appears to be the relaxant of choice, unless contradicted.[3]

3 The authors mention that institutional protocol

is to confirm correct ETT portion before commencement of surgery in FOB-guided awake intubation However, in any such difficult case, the protocol must be in proper conformation before induction of full-fledge GA, or else one may encounter catastrophic events

4 The authors mention that repeated FOB revealed the tonsils at 4 and 7 ‘O clock positions at the distal end of ETT, which means that the tip of ETT must be somewhere around the anterior pillar of the tonsils rather than abutting the pharyngeal inlet Also, repeated ETT cuff inflation was mentioned by the authors, but there was no documentation of up to how much cuff pressure was it inflated to seal the oropharynx of this patient? Thus, that too is misleading

5 Last but not the least, whether the coughing was still present while rail roading the ETT over bronchoscope was not mentioned by the authors If the coughing was present, then the tube might have not properly passed between the vocal cords in the very first instance Moreover, the authors mention that attempts to

“railroad” ETT over FOB may have resulted in loop formation, which indicates that there was definite difficulty in sliding of tube over the FOB Experts say that if repeated attempts to slide ETT over bronchoscope and into the trachea are unsuccessful/firm resistance is met when tip

435 Indian Journal of Anaesthesia | Vol 56| Issue 4 | Jul-Aug 2012

Letters to Editor

of ETT is at the glottic level, the bronchoscope

and tube had to be removed as a unit and the

procedure began again.[3,4] In such cases, there

are chances of “hanging up of Murphy’s tip on

the epiglottis”[5,6]/sometimes the bronchoscope

may have exited the ETT via Murphy’s eye.[4]

Whatsoever be the case, if persistent difficulties

are encountered, ventilating and oxygenating

the patient, protecting his airway as best as one

can and waking him up is the protocol most

experts suggest,[7] and the procedure can be

begun again.[3]

Jitin N Trivedi

Consultant Anaesthetist, Ankleshwar, Gujarat, India

Address for correspondence:

Dr Jitin N Trivedi, Consultant Anesthetist, 12, “Swastik”,

Vrundavan Bunglows, Bhd GEB office, Ankleshwar, Gujarat, India

E-mail: jitinntrivedi@yahoo.co.in

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Website:

www.ijaweb.org

DOI:

10.4103/0019-5049.100855

REFERENCES

1 Chakravarthy M A rare potentially hazardous malposition of the nasotracheal tube Indian J Anaesth 2012;56 Issue –I:81-3.

2 Stoelting RK, Dierdorf SF ‘Anesthesia and Co – Existing Disease’ Fourth ed Harcourt (India) Pvt Ltd.; Philadelphia,

2002 p 441-51.

3 Miller RD 'Anesthesia' 4 th ed Philadelphia, US: Churchill Livingstone; 1994 p 1403-33.

4 Nichols KP, Zarnow MA A potential complication of fiberoptic intubation Anesthesiology 1989;70:562-3.

5 Katsnelson T When the endotracheal tube will not pass over the flexible fiberoptic bronchoscope Anesthesiology 1992;76:151-2.

6 Ovassapian A Fiberoptic nasotracheal intubation – incidence and causes of failure Anesth Analg 1983;62:692-5.

7 Ovassapian A Fibreoptic bronchoscope and unexpected failed intubation Can J Anaesth 1999;46:806-10

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