Gastric Distention and Rupture from Oxygen Insufflation during Fiberoptic Intubation

Abstract

(Hershey) Assistant Clinical Professor.(Hannenberg) Associate Clinical Professor.Received from the Department of Anesthesiology, Newton Wellesley Hospital, Newton, Massachusetts. Submitted for publication June 6, 1996. Accepted for publication August 12, 1996.Address reprint requests to Dr. Hannenberg: Department of Anesthesiology, Newton Wellesley Hospital, 2014 Washington Street, Newton, Massachusetts 02162.Key words: Tracheal intubation: fiberoptic; complications. Stomach: rupture; distention. Insufflation: oxygen.Since its introduction in 1986, [1,2]the use of oxygen insufflation during fiberoptic intubation is recommended by nearly all authorities on airway management. [3,4],*,**,*** The beneficial effects of oxygen administration through the fiberscope include (1) supporting the patient's oxygenation, (2) clearing secretions from the tip of the instrument, and (3) defogging the viewing channel's optics. We report a case in which gastric distention and rupture complicated this technique.A 75-yr-old, 60-kg woman underwent an uneventful right carotid endarterectomy. During the following 48 h, a slowly increasing neck mass developed. She was scheduled for exploration and evacuation of her neck wound. Preoperatively, she was alert, but had difficulty speaking, was dyspneic, and had audible stridor. Airway evaluation revealed a Mallampati class IV airway, some limitation to neck extension, and a large anterior neck hematoma. The larynx could not be identified by palpation or inspection.In the operating room, standard monitors were applied, and the patient was given 0.2 mg glycopyrrolate and 0.5 mg midazolam intravenously. Her upper airway was then sprayed with 4% lidocaine. She vomited small volumes twice during the lidocaine administration. These episodes of vomiting were brief and not unusually forceful. The upper airway was then examined with a Macintosh laryngoscope, and a large, bulging retropharyngeal hematoma was noted. No recognizable structures other than her palate and uvula were visualized.We prepared to perform fiberoptic intubation. The channel inlet of a Pentax FI-10P bronchoscope (Pentax Instrument, Orangeburg, NY) was attached to an oxygen flowmeter that delivered 3 l per minute to provide oxygen insufflation during the intubation. The fiberoptic examination demonstrated grossly distorted and ecchymotic upper airway anatomy. The fiberscope briefly entered the proximal esophagus on several occasions during the procedure. We estimate that the cumulative total time during which the fiberscope was in the esophagus was approximately 60 s. The fiberoptic procedure was initially well tolerated by the patient, but after 20 min, ineffective ventilatory efforts developed, and her oxygen saturation abruptly decreased to less than 50%. With considerable effort, direct laryngoscopy and intubation was then performed by following the