One of the most challenging scenarios to face is a tumor in the airway. Working closely with your surgeon is important. In this particular case, we actually had a video available of what this 8 mm airway polyp looked like popping in and out of a laryngeal opening of about the same size with each breath like a potential cork. According to the surgeon our patient had come to the clinic because she had been experiencing some increased shortness of breath. Having the video was a rare advantage. Follow this link to youtube video showing pedunculated vocal cord polyp obstructing the glottic opening. Here are some stills from that video.
My surgeon recognized that we needed to strategize together to come up with an optimal plan. He needed a smaller than average tube size to allow him to operate on the polyp. He was also worried this might be fragile tissue, easy to bleed. However he felt certain that if I anesthetized her in the normal fashion I would be able to intubate with normal laryngoscopy.
However, I worried that if I did paralyze her for induction and failed to intubate, that I might not be able to ventilate her. The polyp might plug the trachea with manual ventilation.
If I did an awake fiberoptic intubation with the patient breathing, I would be able to pass the fiber into the larynx under direct vision. Unfortunately, I would then have to pass the endotracheal tube down the fiber blindly over the fiber. In the worst case scenario, the tube could catch on the poly, rip the polyp off its stalk and shove it down the trachea — causing bleeding and perhaps airway obstruction down at the carina.
I decided to use the GlideScope, which doesn’t require as much jaw lift as conventional laryngoscopy. This would allow me to pass the tube under direct vision with the patient awake as long as she was well topicalized. The surgical team would also be able to see and comment on the intubation in progress. The surgeon stood by with his tracheostomy equipment nearby just in case things did not go as expected.
After pre-treatment with glycopyrrolate to dry secretions, and some slowly titrated midazolam and fentanyl, I topicalized her oropharynx with local anesthetic spray. I then performed glossopharyngeal nerve blocks to block her gag reflex. I also explained to the patient throughout what she would experience so that there were no surprises that might cause panic.
Using the Glidescope to visualize the larynx, and timing my forward insertion of the tube into the larynx to when the polyp was visible above the cords, I easily passed a 6.0 mm endotracheal tube. We then induced general anesthesia.
There are many different ways to have safely intubated and anesthetized this patient.The important point was that the surgeon and I discussed the concerns and together came up with a plan. We also had plans for what we would do if we lost the airway.
While the Glidescope is usually used to intubate the patient under general anesthesia, it can be used for awake intubation. Using the same preparation as for fiberoptic intubation was quite effective and left open the option of switching to fiberoptic intubation should the attempt with the Glidescope have been unsuccessful. The patient tolerated the procedure well.
In these days of advanced technology, we often avoid awake intubate because of concern of causing the patient pain or distress. However, sometimes awake intubation is the safest way to proceed and if you are gentle and prepare the patient well, it can be comfortable as well. The Glidescope is just another tool you can use for awake intubation.
May The Force Be With You
Christine Whitten MD