Pentax-AWS videolaryngoscope for nasotracheal intubation in patients with difficult airways

Corresponding author: Keon-Sik Kim, M.D., Department of Anesthesiology and Pain Medicine, Kyung Hee University Medical Center, Hoegidong, Dongdaemun-gu, Seoul 130-702, Korea. Tel: 82-2-958-8591, Fax: 82-2-958-8580, 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 It is difficult to intubate with Macintosh laryngoscope or fiberoptic bronchoscope in patients with narrow oropharyngeal space, deformed oro-pharyngeal-larynx structures, or restricted neck movement. The Pentax-AWS (AWS, Pentax, Tokyo, Japan) (Fig. 1) is a rigid video laryngoscope for intubation, which consists of a disposable transparent blade (Pblade), a camera, and a monitor. A target mark on the monitor suggests the tracheal tube direction of advance, facilitating easy and accurate intubation. We report on the use of the AWS for nasotracheal intubation in two patients with oropharyngeal lesions, in whom Macintosh laryngoscopic and fiberoptic bronchoscopic intubation had failed. The first patient was a 56-yr-old man (163 cm, 64 kg), who was presented with right facial palsy after a right radical parotidectomy about 8 months ago due to an adenocystic parotid cancer. He had limited neck motion, which was expected due to the radiation therapy and prior neck dissection. For tensor fascia lata sling operation, anesthesia was induced with a bolus of propofol (2 mg/kg) and rocuronium (0.8 mg/kg) intravenously. We tried to insert a 7.0 mm ID nasal RAE tracheal tube through the nose, because the nasotracheal intubation offers more convenience for surgical maneuvering. Nasotracheal intubation with Macintosh laryngoscope was attempted, but visualization of the glottis was impossible (Cormak and Lehane [C/L] grade 3). Secondly, with passing the fiberoptic bronchoscope (LFTP, Olympus, Fukushima, Japan) (diameter; 5.0 mm) through the nasal RAE tube, we tried to locate the tip of the fiberoptic bronchoscope to the glottis. But it was impossible to see the glottis mainly due to swelling in the pharynx. Next, nasal intubation, with the AWS, was attempted. With the nasal tube in place, the AWS was easily inserted orally with its tip toward the glottic side of the epiglottis, and a full view of the glottis was displayed on the videoscreen. The Magill forceps could not be used because when the AWS was in the mouth, there was not enough space to manipulate a Magill forceps. Also, without any introducer, the tube was smoothly advanced into the trachea without any difficulty by external pressure to the neck for targeting symbol mark. Nasotracheal intubation using the AWS was achieved within 20 seconds. The second patient was a 71-yr-old woman (153 cm, 48 kg), who was scheduled with an operation for a wide excision of