Difficult intubation managed using standard laryngeal mask airway, flexible fibreoptic bronchoscope and wire guided enteral feeding tube

This case report describes an alternative method of achieving trans-oral intubation in a patient with a difficult airway who was apnoeic secondary to the therapeutic administration of a non-depolarizing neuromuscular blocking drug given to aid laryngoscopy. After attempts to intubate were unsuccessful by means of direct laryngoscopy utilizing various aids including bougies, a standard laryngeal mask airway was used to ventilate the patient and subsequently, with a swivel Y-connector attached in order to maintain PEEP, to aid the passage of a bronchoscope. The flexible guide-wire from an enteral feeding tube was then passed through the suction port of the bronchoscope into the trachea, after which the laryngeal mask airway and bronchoscope were withdrawn. By passing the enteral feeding tube over the guide-wire and then using this as a guide, a cuffed endotracheal tube was inserted into the trachea. The technique described permitted the continuous application of positive airway pressure, which dramatically improved the bronchoscopic view during the crucial step of placing the guide-wire into the trachea. Passing the feeding tube over the guide-wire aided the subsequent passage of the endotracheal tube, by acting as a stiffer and larger diameter guide through the glottis.