The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway

Corresponding author: Jie Ae Kim, M.D., Department of Anesthesiology and Pain Medicine, Samsung Medical Center, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Korea. Tel: 82-2-3410-0363, Fax: 82-2-3410-6626, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Recently, video assisted intubation devices have played an important role in difficult airway management. The Clarus Video System (OptiScope, Pacific Medical, Seoul, Korea) is a new video intubating stylet. The use of this airway device has been increasing for difficult airways; however, its use has not been reported for a double lumen endo-bronchial tube (DLT) placement. Here, we describe our experience with the Clarus Video System (CVS) for the placement of a DLT. A 57-year-old male patient (180.7 cm, 81.4 kg) with pulmonary metastases from malignant melanoma was admitted to our hospital for pulmonary metastasectomy by video assisted thoracoscopy. Two years ago, he was diagnosed with malignant melanoma of the lip and underwent ENT surgery, an excision of the tumor, and a submandibular lymph node dissection. After that, he had tomo-therapy (a type of radiation therapy) 5 times and a bronchoscopic biopsy two times with an abnormal position emission tomographic scan. In the preoperative airway assessment, it appeared that the patient had slightly limited neck motion and shortened hyomental distance. The range of his mouth opening was around two finger widths. After adequate preoxygenation, general anesthesia was induced with thiopental 400 mg, sevoflurane and rocuronium 50 mg. Mask ventilation was not difficult, and after obtaining an appropriate depth of anesthesia, we tried to intubate the trachea with a 37 Fr left-sided DLT (Bronchocath, Mallinckrodt Medical Ltd, Ireland). At the first attempt, intubation by direct Macintosh laryngscope using a size 3 blade failed; an inability to expose the epiglottis (CormackLehane Grade 4), a limitation in the handling of the laryngoscope due to limited mouth opening, and neck motion were noted. At the third attempt by direct laryngoscope, his trachea was blindly intubated, but we observed that the tracheal balloon of the DLT was torn. After removal of the DLT, ventilation and oxygenation with a bag and mask continued to be effective, and anesthesia was maintained with a mixture of sevoflurane 5% and oxygen 100%.