1. AbstractInCovid-19pandemic,theuseofvideolaryngoscopefortracheal intubation is highly recommended due to the increasing distance betweenpatient’sairwayandoperator.Anendotrachealtubewith an intubating stylet has been proposed to facilitate tracheal tube insertion, especially when video laryngoscope was used. Thus in routineanesthesiapracticeintubatingstyletisusedasanaidintrachealintubationforconfirmedorsuspectedCovid-19infectedpatients.Atthepresenttime,thedisposableplasticcoveredorplastic bougieismorerecommendedbutinsomeinstitutes,themalleable aluminum stylets are still in use. Though shearing of part of the stylethasbeenreportedinpastbutwereportacasewithasunrecognizedbrokenpieceofstyletintohisrightmainbronchus,which was later extracted immediately and successfully before causing adverse symptoms or hurts
2. IntroductionInCovid-19pandemic,theuseofvideolaryngoscopefortracheal intubation is highly recommended due to the increasing distance between patient’s airway and operator [1]. An endotracheal tube with an intubating stylet has been proposed to facilitate tracheal tube insertion, especially when video laryngoscope was used [2]. Thus in routine anesthesia practice intubating stylet is used as an aidintrachealintubationforconfirmedorsuspectedCovid-19infectedpatients.Atthepresenttime,thedisposableplasticcovered orplasticbougieismorerecommendedbutinsomeinstitutes,the malleablealuminumstyletsarestillinuse.Thoughshearingof part of the stylet has been reported in past3 but we report a case with as unrecognized broken piece of stylet into his right main bronchus,whichwaslaterextractedimmediatelyandsuccessfully before causing adverse symptoms or hurts.
3. Case ReportA21 years old man was admitted in the department of orthopaedics as a case of right clavicle fracture posted for open reduction andinternalclaviclefixation.Onphysicalexamination,hewasan average built man of 174 cm, weighing 62 kilogram. Pre anesthetic evaluation was normal. Airway evaluation did not predict difficult airway. He was classified as anAmerican Society ofAnesthesiologists physical status I (ASAI) and planned for general anesthesia with tracheal intubation. On scheduled day, the patient was taken to operation room and his baseline vital signs were all within normal values. Induction of general anesthesia was done with fentanyl 100 mcq,propofol 150 mg and rocuronium 50 mg intravenous after 5 minutes preoxygenation. Tracheal intubation wasperformedwithendotrachealtube7.5mmIDpreloadedwitha malleablealuminumstylet.Theanesthesiologistusedvideolaryngoscope(GlideScope)forintubationsmoothlybutwhenthestylet was pulled out of the endotracheal tube with a little difficulty and some extra force was needed. The tracheal placement was confirmedbyauscultationandcheckingendtidalCO2concentration. Then the patient was mechanically ventilated with a tidal volume of8mL/kgandrespiratoryrateof10permin.Suddenlytheassitantanestheticnursefoundthelengthofthepreviouslyremove styletappearedshorter,sheinformedandalarmedtheanesthesiologist immediately. On thesuspicion of broken metalof stylet,the anesthesiologistrequestedthesurgeontostopsurgicaldisinfection anddraping,thenthemechanicallyventilationmodewaschanged toartificiallymanuallycontrolledwithalowertidalvolumeinor- der to decrease the positive airway pressure. Theanesthesiologistdecidedtogoaheadwithfiberopticbronchoscopy. The bronchoscopy revealed a metallic mobile foreign body in the night main bronchus (Figure 1).The foreign body then was retrievedwithbiopsyforcepsandbroughtupintotheendotracheal tubeandthenremovedsuccessfullyviatheendotrachealtube.The foreignbodywasanaluminumrodabout4cminlengthand2.5-3 mm in diameter (Figure 2). It looked like the malleable stylet and matched the size with the residual stylet (Figure 3).The was no bleeding or mucosa injury during the procedure. After removal, check bronchoscopy was performed, and the airways visualized both the sides up to the sub segmental level were all clear. Then the surgery was proceeded which lasted for 115 minutes and the intra-operation period remained uneventful. After completion of surgery, he was extubated and sent to the post operating recovery room smoothly. No cough, dyspnea and desaturation was noted.
4. DiscussionTrachealintubationofpatientswithcoronavirusdisease-19(Cov- id9)isapotentiallyaerosol-generatingprocedurethatrequiresa carefulandefficientapproachtoensurethesafetyofbothpatients andhealthcareproviders(HCPs)[4].Manyguidelinesrecommend the use of video laryngoscopes to increase the operator’s distance from the patient’s airway and the chance of first-pass success [1]. Whendonnedwithpersonalprotectiveequipment(PPE),thefirstpasssuccessrateandintubationtimewithvideolaryngoscopesare not affected when compared with direct laryngoscope [5]. IatrogenicInhaledforeignbodymightcontributetosignificantmortalityandmorbidity[6].Fortunately,earlydetectionandimmediately proper action of our case greatly reduced the potential harm of this rare complication. Broken pieces of metallic stylet resulting inpartialendotrachealtubeobstructionhasbeenreportedbymany scholars[7,8].Butinourcase,weobservedthebrokenstylethav- ing migrated into the right main bronchus. This worsen the situationthatwasalreadydifficultanddangerous.Aluminumstylethad been used which happened to be weakened leading to its fracture at the most vulnerable part. The main reason behind the breaking ofthestyletwassignificantoveruse.Sincetherearenoclearmarkingsinthestylet,itsbreakagewentunnoticedafterintubationand further management of the patient was continued. Fortunately the anestheticnursewasveryalertandnoticedtheunusualshortening of the stylet. Thus we strongly recommend careful evaluation of airwaymanagementequipmentbeforeandafterprocedurestoprevent such iatrogenic complications.
5. ConclusionsWe would like to conclude that a routine, regular check of equipment be performed to avoid such iatrogenic complication. If the removal of the stylet was difficult, the anesthesiologist should carefully examine the stylet to note if any portion of it has been damaged,brokenorshornoffintotheendotrachealtubeortracheobronchial tree.
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2. Berkow LC, Morey TE, Urdaneta F. The Technology of Video Laryngoscopy. Anesth Analg. 2018; 126(5):1527-1534.
3. SharmaA, Jain V, Mitra JK, Prabhakar H.Arare cause of endotracheal tube obstruction: a broken stylet going unnoticed--a case report. Middle East J Anaesthesiol. 2008; 19(4):909-911.
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AlbertChen. Successful Management of a Broken Stylet Retainedin Tracheobronchial Tree: A Case Report . Annals of Clinical and Medical Case Reports 2022