Fiberoptic Tracheal Intubation Through a Laryngeal Mask Airway in a Child with Treacher Collins Syndrome

Anesthetic Management of Treacher Collins Syndrome in an Outpatient Surgical Center

Patient: Male, 15-year-old

Final Diagnosis: Treacher Collins syndrome

Symptoms: Difficult airway management

Medication:—

Clinical Procedure: —

Specialty: Anesthesiology

The design of the perfect pediatric supraglottic airway device

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the  supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of  supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome

Case report

Conclusion

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome]

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al.

CASE REPORT

An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube.

CONCLUSION

The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome.

Comparison of the air-Q intubating laryngeal airway and the cobra perilaryngeal airway as conduits for fiber optic-guided intubation in pediatric patients

BACKGROUND

One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients.

MATERIALS AND METHODS

A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications.

RESULTS

Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH2O vs. 16.3 ± 4.5 cmH2O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat.

CONCLUSION

Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.

Anesthesia for Treacher Collins syndrome: a review of airway management in 240 pediatric cases

OBJECTIVES

To review airway management with anesthesia for children with Treacher Collins syndrome (TCS) and determine whether intubation was more difficult with increasing age.

BACKGROUND

Treacher Collins syndrome is a rare disorder of craniofacial development characterized by maxillary, zygomatic, and mandibular dysplasia. TCS is associated with difficult intubation, but reports of airway management are limited to case reports and small cases series. Children with TCS may require multiple general anesthetics, and it has been suggested that intubation becomes more difficult with increasing age.

METHODS

A retrospective case note review of children with TCS from birth to 18 years undergoing anesthesia from 1971 to 2011 in a single center was performed. Demographic data, procedure type, anesthesia type, method of airway management, modified Cormack-Lehane (MCL) grade of laryngoscopic view, and any other descriptions of airway difficulty or complications were collated.

RESULTS

Of 59 patients with TCS, 35 children underwent a total of 240 anesthetics, most commonly for craniofacial surgery. Final airway management consisted of face mask 17%, laryngeal mask airway 16%, endotracheal intubation 49%, and 18% had a preexisting tracheostomy. The laryngeal mask airway provided an adequate airway in all cases when it was used. MCL grade was recorded in 97 cases involving 28 patients: 7% grade 1, 9% grade 2a, 31% grade 2b, 26% grade 3, and 27% grade 4. Fifteen (54%) patients were MCL grade 4 on at least one occasion. Failed intubation occurred in 6 (5%) of 123 cases of planned intubation. The procedure was canceled in two cases (0.8%) because of failure to intubate. Intubation techniques other than conventional direct laryngoscopy were used in 41% of cases. MCL grade increased with increasing age (P = 0.007).

CONCLUSIONS

Most children with TCS have difficult laryngoscopic views with many requiring specialized intubation techniques. Direct laryngoscopy becomes more difficult with increasing age. The laryngeal mask airway is a good choice of airway when endotracheal intubation is not required.

Use of the Laryngeal Mask Airway-Aintree Intubating Catheter-fiberoptic bronchoscope technique for difficult intubation

STUDY OBJECTIVE

To determine whether intubation using an Aintree Intubation Catheter (AIC), fiberoptic intubation (FOB), and Laryngeal Mask Airway (LMA) is safe and effective for securing the airway in patients who are difficult to intubate after induction of general anesthesia.

DESIGN

Retrospective review of departmental difficult airway database procedures completed between July 2006 and December 2009.

SETTING

Academic medical center.

MEASUREMENTS AND MAIN RESULTS

During the study period, 128 of 500 patients entered into the difficult airway database underwent the LMA-AIC-FOB technique for intubation. One hundred nineteen (93%) of the 128 patients were successfully intubated by the LMA-AIC-FOB technique, and 9 required an alternate technique. No patient who underwent the LMA-AIC-FOB technique experienced an airway-related mortality or required an emergency surgical airway procedure.

CONCLUSION

The LMA-AIC-FOB technique is safe and effective for patients who are difficult to intubate after induction of anesthesia.

Simple, reliable replacement of pilot balloons for a variety of clinical situations

When a pilot balloon fails or is an impediment to an intubation, such as via a pediatric laryngeal mask, options are generally limited to a tracheal tube exchange. Simple and effective solutions are described to replace a pilot balloon in a variety of clinical situations by using equipment that is readily available in operating rooms. Equipment such as intravenous catheters or epidural clamp connectors provides reliable, light weight, and streamlined substitutions for pilot balloons when connected to the pilot-cuff inflation line.

[Use of a metal guide in the working channel of a fiberoptic scope to insert a tracheal tube in an infant with Treacher Collins syndrome and choanal atresia]

Neonates with Treacher Collins syndrome can present difficult airways. Ventilation through a face mask and laryngoscopy for tracheal intubation may prove impossible due to the craniofacial malformations that are characteristic of this syndrome. Furthermore, patients with this syndrome are at high risk of airway obstruction, meaning that awake fiberoptic endoscopy provides the best option for tracheal intubation. This technique is especially difficult in children, however, and material required for performing it in neonates is not always available. We report the case of a 5-day-old infant boy with Treacher Collins syndrome and bilateral choanal atresia in whom we used a flexible metal guide inserted into the working channel of a fiberoptic scope. The tracheal tube could then be inserted.

The management of difficult intubation in children

This article looks at the current techniques and equipment recommended for the management of the difficult intubation scenario in pediatric practice. We discuss the general considerations including preoperative preparation, the preferred anesthetic technique and the use of both rigid laryngoscopic and fiberoptic techniques for intubation. The unanticipated scenario is also discussed.

Management of the upper airway and congenital cystic lung diseases in neonates

Congenital upper airway obstruction can pose difficult problems immediately after birth. Newer strategies to maintain the airway in such situations include pharyngeal ventilation, the laryngeal mask airway and flexible fibreoptic intubation. These methods have decreased the potential for malformations such as Pierre Robin sequence to cause perinatal hypoxia. The most devastating upper airway problem is total obstruction at the supraglottic, glottic or tracheal level without tracheo-oesophageal communication. This can usually be detected prenatally and its management may include the use of the EXIT (ex-utero intrapartum) procedure. Congenital space-occupying lesions of the lung can be detected prenatally with ultrasound. Their management must be individualised, as their pre- and postnatal development is difficult to predict. Very large lesions can lead to lung hypoplasia or fetal hydrops. Management may include prenatal surgery, shunting and, rarely, an EXIT procedure during birth. A few children may require extracorporeal membrane oxygenation postnatally.

Airway management in infants and children

Anaesthesiologists, paediatricians, paediatric intensivists and emergency physicians are routinely challenged with airway management in children and infants. There are important differences from adult airway management as a result of specific features of paediatric anatomy and physiology, which are more relevant the younger the child. In addition, a number of inherited and acquired pathological syndromes have significant impact on airway management in this age group. Several new devices--e.g. different types of laryngeal mask airways in various sizes, small fibre-endoscopes--have been introduced into clinical practice with the intention of improving airway management in this age group. Important new studies have gathered evidence about risks and benefits of certain confounding variables for airway problems and specific techniques for solving them. Airway-related morbidity and mortality in children and infants during the perioperative period are still high, and only a thorough risk determination prior to and continuous attention during the procedure can reduce these risks. Appropriate preparation of the available equipment and frequent training in management algorithms for all personnel involved appear to be very important.

Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway

BACKGROUND

Induction of anesthesia and tracheal intubation in small children with a difficult airway is a challenging task. We report the experience with a procedure based on sevoflurane inhalation via a nasopharyngeal airway inserted early during induction before airway obstruction occurs. A pediatric fiberscope is used to perform a nasotracheal intubation via the opposite nostril.

METHODS

All small children with suspected or known difficult airway needing tracheal intubation were scheduled for a fiberoptic intubation following the described protocol.

RESULTS

In 3 years, we performed 27 successful fiberoptic guided tracheal intubations in 19 children, median age 8.2 months (1.0-39.1 months) and median weight 7.6 kg (3.0-15.0 kg). The optimal depth for placement of the nasopharyngeal airway was found to be 8.0 cm (7.0-8.5 cm) from the nostril in the first year of life and 8.5 cm (8.0-10 cm) in the second year. Oxygenation was sufficient during the entire procedure in all cases except one child who had short-lasting laryngeal spasm caused by instillation of lidocaine during light anesthesia. The duration of fiberoptic intubation was significantly shorter when performed by an experienced anesthesiologist (55 s vs. 120 s), but there was no significant correlation between the duration of fiberoscopy and oxygen saturation during fiberoscopy or endtidal CO(2) after intubation.

CONCLUSION

The combination of nasopharyngeal airway and fiberoptic guided tracheal intubation seems to be a reliable and safe procedure for managing the difficult airway in small children.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

Sedation and fiberoptic intubation of a neonate with a cystic hygroma

The flexible bronchoscope (FB) has been used to secure the difficult airway in pediatric patients. Difficult intubations in patients with cystic hygromas have been performed in awake patients or after the induction of general anesthesia. A recent case report acknowledges the challenges of performing intubations in pediatric patients under sedation because of their inability to fully cooperate. The following case demonstrates the two step-two fiberoptic bronchoscopic tracheal intubation performed using sedation and topical anesthesia in a neonate with a difficult airway.