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A combination of KingVision videolaryngoscope and flexible fibroscope for awake intubation in patient with laryngeal tumor – case report and literature review text
Department of Emergency Medicine and Disaster Medicine, Medical University of Łódź, Poland
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Gaszyński T: A combination of KingVision videolaryngoscope and flexible fibroscope for awake intubation in patient with laryngeal tumor – case report and literature review. Anaesthesiol Intensive Ther 2015; 47: 433-435. 10.5603/AIT.a2015.0019.
Intubation of patients with a supraglottic mass causing an obstruction of the glottis is difficult even for experienced anesthesiologists. We present our case of combined use of KingVision videolaryngoscope (King Systems, Noblesville, USA) and flexible fibroscope for awake intubation of patient with laryngeal tumor. Patient’s written consent was obtained for publication. A 83-yrs old male was admitted to Department of Laryngology at Barlicki University Hospital, Poland for treatment of laryngeal tumor. Patient had former history of treatment of laryngeal cancer with radiotherapy. At moment of admission patient suffered from sore throat, problems with speaking and sleep disturbances caused by respiration difficulties. He was scheduled for urgent tracheostomy. Because of radiotherapy typical attempt of tracheostomy under local anesthesia was not possible. Following discussion with specialist he was scheduled fortracheostomy under general anesthesia with endotracheal intubation. After larynx indirect examination it appeared that entrance to larynx is not visible and tumor mass is covering epiglottis and entrance to larynx. This was confirmed in CT scans. It was decided to perform awake fibroptic intubation under local anesthesia. Patient was anesthetized using 4% lidocaine spray topical anesthesia in typical method for bronchoscopy. A 0.1 mg of fentanyl and 0.5 mg of atropine was administrated iv. Dexmedetomidine infusion was commenced with loading dose of 1 μg kg-1 over 10 minutes and then at ratio 0.5 μg kg-1 h-1. Awake fiberoptic intubation was started as soon as the patient reached a Ramsay sedation scale score of 4. An experienced brochoscopist was attempting fibroptic intubation (Lipp-Golecki set intubation fibroscope, Karl Storz,Tuttlingen, Germany). Unfortunately he could not find entrance to larynx not from oral nor from nasal approach. We decided to use KingVision videolaryngoscope to attempt visualization of entrance to larynx.When introducing gently videolaryngoscope it was possible to elevate tumor mass with the tip of videolarygoscope blade and visualize entrance to larynx. Then the fibroscope was introduced in the ET tube channel of videolaryngoscope and proceeded to the trachea (Fig. 1). Patient was intubated with ETtube no 7 with no complications and general anesthesia was commenced with propofol infusion. Surgery and perioperative period was uneventful.
To the best of our knowledge it is first report of combine use of KingVision videolaryngoscope and flexible fibroscope for awake intubation. Greib et al.  used DCI videolaryngoscope (Karl Storz, Tuttlingen, Germany) which is very different in construction and operation to KingVision which is from the group of videolaryngoscopes with ET tube chanel incorporated into blade. We used similar method of local anesthesia for our patient with success. Additional opioid is very effective to attenuate reflexes from posterior wall of pharynx and entrance to larynx during fibroscopy. Xue et al.  reported 13 cases of awake combined Glidescope – fibroscope intubation. In our case, the same as in Xue’s report we administrated fentanyl with good effect. Choi et al.  reported awake combined Glidescope – flexible fibroscope intubation in patient with an elliptic tumor mass about 4 cm in diameter chich was blocking almost all of the top part of the glottis. They used remifentanil infusion as opioid. The number of report of combined use of videolaryngoscopes and flexible fibroscopes is limited. Other studies found in PubMed are on intubation under general anesthesia. The study of Greib et al was performed on patients under general anesthesia . Moore et al.  described use of Glidescope and fibroscope in morbidly obese woman but also under general anesthesia
What is worth to mention, in case of Glidescope videolaryngoscope it may be necessary to introduce ET tube with stylet first nearby entrance to larynx, then remove the stylet and place fiibroscope into ET tube and then it could be proceeded into trachea . In case of KingVision because of ET channel incorporated into blade the insertion of fibroscope was easer without former insertion of ET tube. It should be easer and require less mannouvers comparing to method of Xue et al. in which Glidescope operator had to inform bronchoscopist about position of tip of fibroscope .
Very interesting concept of using combination of videolaryngoscope and fiberoscope called „smart stylet” technique was presented by Weissbrod and Merati . Entrance to larynx is visualized by videolaryngoscope but fiberoscope is used only as stylet with moveable tip-not for visualization of glottis.
As conclusion we assume that the use of KingVision videolaryngoscope combined with flexible fibroscope for awake intuabtion under dexmedetomidine sedation can be a good option in patients with suspected difficult intubation and it may be easer to use and more effective comparing to other videolaryngoscopes and/or fibroscope alone.
- The authors declare no financial disclosure.
- The authors declare no conflict of interest.
- Greib N, Stojeba N, Dow WA, Henderson J, Diemunsch PA: A combined rigid videolaryngoscopy-flexible fibrescopy intubation technique under general anesthesia. Can J Anaesth 2007; 54: 492-493.
- Xue FS, Li CW, Zhang GH, Li XY, Sun HT, Liu KP et al.: GlideScope-assisted awake fibreoptic intubation: initial experience in 13 patients. Anaesthesia 2006; 61: 1014-1015.
- Choi GS,Park SI, Lee EH, Yoon SH: Awake GlideScope®intubation in a patient with a huge and fixed supraglottic mass. A case report. Korean J Anesthesiol 2010; 59 (Suppl): S26-S29. doi: 10.4097/kjae.2010.59.S.S26.
- Moore MSR, Wong AB: GlideScope® intubation assisted by fiberoptic scope. Anesthesiology 2007; 106: 885.
- Weissbrod PA, Merati AL: Reducing injury during video-assisted endotracheal intubation: the „smart stylet” concept. Laryngoscope 2011; 121: 2391-2393. doi: 10.1002/lary.22167.
Prof. Tomasz Gaszyński MD, PhD
Department of Emergency Medicine and Disaster Medicine
Barlicki University Hospital
ul. Kopcińskiego 22, 90-153 Łódź, Poland