Yet another modification of Guedel’s airway recovery

Flexible fibreoptic laryngoscopic intubation (FFLI) is a very reliable approach to difficult airway management. [1] Oral FFLI is considered more difficult than nasal FFLI as the tip enters the larynx at an acute angle to the glottis.[1] In anaesthetised patients, there is loss of tone in the submandibular muscles, tongue and indirectly the epiglottis. Flexible fibreoptic laryngoscope (FFL) is expensive, delicate, and the cables are not strong enough to lift or dislodge the tissues.[1] A number of fibreoptic-compatible oral airways (FCOAs) have been designed to protect the instrument from the patient’s teeth, guide it into the midline and keep the tongue from falling backwards. [2]


Yet another modification of Guedel's airway
Sir, Flexible fibreoptic laryngoscopic intubation (FFLI) is a very reliable approach to difficult airway management. [1] Oral FFLI is considered more difficult than nasal FFLI as the tip enters the larynx at an acute angle to the glottis. [1] In anaesthetised patients, there is loss of tone in the submandibular muscles, tongue and indirectly the epiglottis. Flexible fibreoptic laryngoscope (FFL) is expensive, delicate, and the cables are not strong enough to lift or dislodge the tissues. [1] A number of fibreoptic-compatible oral airways (FCOAs) have been designed to protect the instrument from the patient's teeth, guide it into the midline and keep the tongue from falling backwards. [2] We have devised a modification of Guedel's airway by removing the palatal surface of the airway [ Figure 1]. The tracheal tube is threaded onto the fibrescope before laryngoscopy. The modified airway keeps the FFL tip around the back of the tongue, in the midline position and close to the larynx till it enters the trachea. The airway can be removed with a lateral twist movement without disturbing the endotracheal tube-endoscope assembly. Following this, the tracheal tube is advanced and the FFL is withdrawn.
On comparing it with anterior (lingual) channel like the Patil-Syracuse and the Williams airway intubator, the latter have the advantage of better localisation of the glottis opening but need to be removed from the oropharynx before a tracheal tube can be advanced over the fibre optic cable into the glottis, creating an unnecessary extra step. [1] McGinley and McAdoo [3] devised a modification of Guedel's airway with deficiency in anterior support. However, at times, the tip of the FFL gets lodged in the pyriform fossa due Sir, I read with interest the recent case report by Kalra. [1] titled "Role of amino acid infusion in delayed recovery from neuromuscular blockers". I admit that it was difficult to establish a differential diagnosis in this case regarding the cause of excessive sedation and unresponsiveness seen in the post operative period. The authors have been resourceful indeed in using amino acid infusion to correct hypothermia, which is a very novel approach.
However, I feel that this particular situation could have been avoided had there been a continuous monitoring of body temperature intraoperatively. Because this is included among standard monitors, [2] one must always ensure that a temperature probe be used for all procedures being performed under any type of anaesthesia. Elderly and frail patients, as this patient definitely was, are extremely prone to develop hypothermia even during short duration procedures. So it was all the more important to monitor her temperature. Most of our current monitors have either a nasopharyngeal or surface temperature probe and, so now it is not at all cumbersome to monitor the thermal status of patients.
Another point that is worthy of discussion is that the dose of fentanyl could have been reduced as we all know that it is highly extracted by the liver and, therefore, its clearance depends on the hepatic blood flow, which is positively reduced in old age. It is preferable to reduce the dosage of fentanyl by 50% in these patients. [3] This would reduce the incidence of bradycardia and respiratory depression seen in the post anaesthesia care unit.
to the deficiency in anterior support. Oral airways with a posterior channel, such as the Ovassapian and Berman, facilitate easy fibreoptic oro-tracheal intubation. Each can be rapidly removed from around the tracheal tube except for Burman's airway as it has both posterior and lateral channels. [1] We have done a pilot study comparing both lingual and palatal modifications of Guedel's airway and found that the palatal modification of Guedel's airway makes FFLI easy, keeps the FFL in midline, no addition manoeuver like jaw thrust is required and causes no disturbance of endotracheal tube-laryngoscope assembly. A possible limitation of the modification would be lack of standardisation. Geudel's airway is available in many sizes as compared to other FCOAs, making it versatile, cost-effective and highly acceptable.
Metallic foreign object in postoperative chest radiograph?

Sir,
A 63-year-old male underwent beating heart coronary artery bypass surgery at our institute. Post procedure, the patient was shifted to Cardiac Recovery with endotracheal tube, Swan Ganz catheter and femoral arterial cannula in situ. The procedure was completed uneventfully, with complete counts of all the materials used by the surgeon for the surgery. The on-duty resident found a radio opaque coiled wire like shadow lateral, to the right sternal border in the third intercostal space (ICS) on a post operative chest radiograph anteroposterior view [ Figure 1]. The presence of this unique foreign body raised a suspicion.
At the first instance the possibility of a metallic object being left in was thought of, but it was ruled out on the