Fiberoptic bronchoscopic nasotracheal intubation in children

Children with Limited Oral Opening Can Be Safely Managed without a Tracheostomy

Objective

To describe airway management of children with limited oral opening that does not allow for routine orotracheal intubation by direct laryngoscopy. To analyze the incidence and outcome of airway compromise or loss in patients without a tracheostomy in place.

Study Design

Case series with chart review.

Setting

Tertiary children’s hospital.

Subjects

Children with limited oral opening that does not allow for routine orotracheal intubation.

Methods

Children treated at Children’s Hospitals and Clinics of Minnesota from 1997 to 2012 with severe trismus were identified and included in the study. Hospital and clinic records were reviewed.

Results

Ten children (mean age, 13 years; range, 7-17 years) were identified for inclusion into the study. A total of 109 operations requiring general anesthesia (average of 10.9 per patient; range, 0-23) were performed on patients without a tracheostomy in place. Flexible fiber-optic nasotracheal intubation was performed in 58 cases. The remainder of airway control was by mask ventilation (33 cases), various methods of orotracheal intubation (10 cases), unknown (6 cases), and laryngeal mask airway (2 cases). There was a total of 118 patient-years of follow-up without a tracheostomy tube in place (average of 11.8 years per patient). During this period, there were no episodes of acute airway compromise that resulted in neurologic deficits.

Conclusion

Children with limited oral opening that does not allow for routine orotracheal intubation with direct laryngoscopy may be safely managed without a tracheostomy, even when the child requires frequent procedures under general anesthesia.

Floor of mouth masses in children: proposal of a new algorithm

OBJECTIVE

Many surgical techniques have been described to manage floor of mouth masses, but few studies have described the approach to these masses in children. This case series summarizes a single institution's experience with pediatric floor of mouth masses.

METHODS

We performed a retrospective chart review of all children who presented at our tertiary care facility with FOM masses between 2007 and 2012. Charts were reviewed for clinical presentation, preoperative, intraoperative and postoperative management.

RESULTS

Thirteen cases were retrieved: 6 dermoid cysts, 4 ranulas, 1 lymphatic malformation, 1 imperforate submandibular duct, and 1 enlarged salivary gland. In 10 of 13 patients, clinical diagnosis was consistent with postoperative diagnosis. Imaging was consistent with postoperative diagnosis in 8 of 9 cases. Ten of 13 masses were managed transorally; 7 were excised, 2 were marsupialized and 1 was managed with submandibular duct dilation. Three masses with a larger submental component, 2 dermoids and 1 ranula, were removed transcervically. Most patients undergoing transoral excision underwent nasotracheal intubation; patients who underwent marsupialization underwent orotracheal intubation. There were no recurrences, complications or postoperative infections. An additional surgical procedure was necessary in one patient.

CONCLUSION

Our cohort displays a common distribution of lesion types when compared to the literature. Low recurrence and infection rates are observed when oral masses are removed transorally, and masses with a larger cervical component are removed transcervically. More complex masses may warrant additional surgical procedures.

Fibreoptic and videoscopic indirect intubation techniques for intubation in children

Endotracheal intubation in the pediatric emergency department can be challenging. Direct laryngoscopy is the primary intubation technique used in pediatric emergency intubations. However, cases arise where abnormalities of the upper airway prevent a direct view of the laryngeal opening. Under these circumstances, indirect means of visualization of the laryngeal opening using fiberoptic and videoscopic devices can be used to successfully achieve intubation. A wide range of instruments including flexible, rigid, and semirigid devices are available. Those who practice emergency medicine should be aware of these devices and be skilled in their use and aware of their limitations.

Pediatric fiberoptic bronchoscopy: Clinical experience with 2,836 bronchoscopies

OBJECTIVE: To report 21 yrs of experience with pediatric flexible fiberoptic bronchoscopy in infants and children, explore newer applications, delineate potential complications, and make recommendations for its future application. DESIGN: Retrospective review. SETTING: A 20-bed pediatric critical care unit in a tertiary care, university-based children's hospital. PATIENTS: A total of 2,836 pediatric and infant fiberoptic bronchoscopies, performed over a course of 21 yrs, were reviewed. Measurement and MAIN RESULTS: A total of 2,836 children (1,536 girls) were subjected to flexible fiberoptic bronchoscopy. Of those, laryngeal mask airway was incorporated in 92 procedures (3.2%) and general anesthesia was applied in 198 cases (7%). The youngest subject was a 1-wk-old, 600-g, premature infant. The procedure resulted in diagnoses that modified patient care, particularly in tracheostomized infants and those with upper airway obstruction, plastic bronchitis of acute chest syndrome, dyskinetic cilia syndrome, immunocompromised individuals, and those with unexplained chronic cough and recurrent pulmonary infiltrates. Microbiologic and cytologic data from bronchoalveolar lavage helped confirm the diagnoses of pulmonary hemosiderosis and gastroesophageal reflux and validated the presence, or lack of, bacterial or viral pathogens. A total of 21 patients (<1%) experienced life-threatening hypoxemia, prompting termination of the procedure. Laryngospasm or bronchospasm was observed in 17 individuals (<1%) undergoing bronchoalveolar lavage, and 4% of the total population experienced mild nasopharyngeal bleeding. No fatalities were encountered. CONCLUSIONS: Pediatric flexible fiberoptic bronchoscopy is a safe diagnostic and interventional tool, even in young or extremely premature infants. Although the rate of serious complications in this report is low, general anesthetic agents and incorporation of laryngeal mask airway is advocated for severe mucoid impaction, transbronchial biopsy, and chronic pulmonary infiltrates, which may necessitate extensive bronchoalveolar lavage.

The flexible bronchoscope. A tool for anesthesiologists

Fiberoptic intubation is the technique of choice in management of a difficult intubation. It should be a first choice, not a last resort after attempts with conventional techniques have failed. It should be mastered by all physicians involved in airway management. The technique is cost-effective because it avoids airway trauma and cancellation of surgical cases because of failed intubation. The flexible bronchoscope for airway management as a diagnostic, therapeutic, and problem-solving tool is not used to the degree that it deserves. Anesthesiologists and other critical care physicians should master the technique and use it on a daily basis. The widespread use of the instrument for airway management deserves encouragement.

Fibreoptic nasal intubation in children with anticipated and unanticipated difficult intubation

The establishment of a tracheal airway with direct laryngoscopy can be either a very difficult or an impossible task in children with congenital or acquired facial malformations. Out of 46 patients categorized as difficult tracheal intubation, fibreoptic laryngoscopy was used successfully in 44 children anaesthetized by mask with sevoflurane and oxygen or by an intravenous infusion of propofol and mask oxygenation. There were two failures (4.3%). One was due to excessive bleeding and secretions produced by the multiple attempts to intubate with direct laryngoscopy and the other failure in a patient with Pierre Robin syndrome and very small nasal passages that precluded the introduction of the endoscope. Fibreoptic laryngoscopy was successful in 37 cases (80.4%) on the first attempt to intubate and in seven (15.2%) on a second or third attempt. We conclude that fibreoptic laryngoscopy in anaesthetized children with difficult anticipated or unanticipated tracheal intubation in trained hands is a safe technique that can be lifesaving. Therefore, we urge all anaesthesia trainees to become proficient in fibreoptic tracheal intubation.

Transcutaneous cricolaryngeal illumination as an adjunct during orotracheal intubation

Transcutaneous cricolaryngeal illumination is an adjunct visualization technique that is useful during orotracheal intubation. A pilot study demonstrated that light from an external high-intensity cool-light source applied to the anterior neck, over the cricothyroid membrane, resulted in transillumination of the glottis in 70% of patients and provided enhanced laryngoscopic visualization of anatomic structures during oral endotracheal tube placement.

A new technique for transbronchial biopsy in infants and small children

We describe a technique of transbronchial biopsy (TBB) in small children, using a plastic suction catheter as the working channel through which biopsy forceps are introduced. An ultrathin (2.2 mm) flexible fiberoptic bronchoscope (FFB) was used to direct the catheter visually into the desired lung segment and to biopsy selectively. This technique was used nine times to obtain biopsy specimens in six different patients, ranging in age from 3 months to 3 and 4/12 years (mean, 19.2 months). Adequate specimens were obtained in eight of nine procedures (89%). Complications included one pneumothorax that did not require evacuation and one episode of sedation-induced hypoventilation that required brief bag-mask ventilation. No significant bleeding occurred. This technique enabled us to obtain lung tissue in infants and small children without resorting to general anesthesia and rigid bronchoscopy.

Usefulness of miniature flexible fiberoptic bronchoscopy in children

A miniature flexible fiberoptic bronchoscope (FFB) (Olympus BF-N20) (2.2 mm diameter) was applied to 53 children (20 female subjects) ranging in age from 3 months to 15 years (mean, 4.19 years). Most common indications for bronchoscopy included stridor or weak cry and persistent wheezing or cough unresponsive to inhaled bronchodilators, chest physiotherapy, steroids, and antimicrobial agents. There were no complications. In 38 children (71.6 percent) it was diagnostically useful, particularly for the investigations of upper airway obstruction (66 percent). In 22 children (41.5 percent) it provided guidance for surgical interventions. The instrument was particularly useful during its application in infants with severe upper airway obstruction who otherwise would require open rigid-tube bronchoscopy in the operating room. It was of limited value when excessive bronchial secretions obstructed the view of the working field for which a bronchoscope with a built-in suction channel was needed. It is concluded that this miniature FFB is a useful diagnostic tool in infants and children particularly for obstructed upper airways but has limited applications in children with peripheral airway disease. The 2.2-mm bronchoscope may have its greatest advantage in preterm neonates and intubated infants, where the small glottic or endotracheal tube size renders the 3.5-mm bronchoscope useless.

Comparison of a rigid laryngoscope with the ultrathin fibreoptic laryngoscope for tracheal intubation in infants

The flexible ultrathin fibreoptic laryngoscope allows placement of endotracheal tubes as small as 2.5 mm internal diameter. The purpose of this study was to document the safety and efficacy of intubation using an ultrathin fibreoptic laryngoscope. Proved safety and efficacy would justify the routine use of fibreoptic laryngoscopy in normal infants to maintain skills needed for management of the difficult infant airway. In this prospective study, 40 infants < 24 mo of age scheduled for elective surgery were randomly divided into two equal groups. After inhalation induction of anaesthesia, in 20 infants the trachea was intubated using direct rigid laryngoscopy, and in 20 using the ultrathin fibreoptic laryngoscope (size 1.8 mm OD) Olympus LFP. Time to successful intubation was recorded, as well as blood pressure, heart rate, end-tidal CO2 and oxygen saturation. Airway trauma in the operating room, the post-anaesthesia care unit, and on the first postoperative day was recorded. The intubation times using rigid laryngoscopy were less than those using fibreoptic laryngoscopy (13.6 +/- 0.9 sec (mean +/- SEM) vs 22.8 +/- 1.7 sec; P < 0.01). Oxygen saturation and end-tidal CO2 readings were not different between the two groups. After intubation, blood pressure and heart rate increased equally in both groups, returning to normal within one to two minutes. There was no difference in the airway trauma between groups. We conclude that the ultrathin fibreoptic laryngoscope is a safe and effective method for tracheal intubation in infants and may be used routinely in order to maintain fibreoptic airway skills.

Fibreoptic intubation

Although not widely utilized, fibreoptic techniques represent a dramatic advance in the management of the difficult intubation. Particularly suited to the awake patient in the elective setting, fibreoptic intubation can also be useful in selected emergency situations, and can be done under general anaesthesia. In the awake patient fibreoptic intubation maintains a wide margin of safety while producing minimal patient discomfort, but requires adequate local anaesthesia of the airway. Intimate familiarity with the bronchoscope and the anatomy of the upper airway is essential as is careful attention to various aspects of technique. Intubation mannequins can be readily utilized to develop dexterity in bronchoscopic manipulation and intubation workshops are also effective in improving skills. This CME article provides the clinician with a detailed approach to the technique of fibreoptic intubation based on the author's personal experience supplemented by a limited literature review. Fibreoptic intubation is not a difficult skill to master and should be in the armamentarium of all practising anaesthetists.

Update on pediatric flexible bronchoscopy

Technological advances in flexible bronchoscopy have expanded the clinician's ability to diagnose and treat pulmonary disease in children. During the neonatal period, flexible bronchoscopy has contributed to the understanding of the incidence and factors responsible for acquired airway lesions. The ability to selectively collect lower airway secretions has contributed to the care of immunocompromised patients with new pulmonary infiltrates. New therapies may use the flexible bronchoscope to specifically target lower airway tissues of interest. Because of the breadth of both current and future applications, most pediatricians will require a working familiarity with the benefits of flexible bronchoscopy in their patients.

Airway management and sedation for pediatric transport

Appropriate airway management is essential for the successful transport of sick children. Airway management begins with a thorough history and physical examination and may proceed to invasive therapeutic interventions. Successful care of the pediatric airway can be achieved only with a thorough knowledge of airway management technique and equipment. In addition, familiarity and understanding of the pharmacologic adjuvants to airway management and sedation will help to achieve the primary objective of any transport team, namely a safe and smooth transport of the critically ill child.

Fiber-optic bronchoscopic guidance for intubating a neonate with Pierre-Robin syndrome

The Pierre-Robin anomalad features micrognathia, glossoptosis, and frequently a cleft palate. Tracheal intubation may be challenging and sometimes impossible. Reported is a case in which a tracheal guide wire was passed via the suction port of a flexible pediatric bronchoscope. The bronchoscope was then removed, and an endotracheal tube was threaded over the wire. The technique is safe and allows rapid endotracheal intubation in pediatric patients with difficult upper airways.

Fiberoptic intubation in the emergency department

Fiberoptic-aided endotracheal intubation has been shown to be effective in difficult intubation secondary to anatomic abnormalities and traumatic conditions. A retrospective review of emergency airway management in an emergency department during a 30-month period found 35 patients who underwent fiberoptic-aided endotracheal intubation; 31 were treated for medical conditions, and four were trauma patients. Indications in the medical group included failed nasotracheal intubation (ten), anatomic abnormalities (six), and the initial airway maneuver attempted (15). Indications in the trauma group with suspected cervical-spine injury included failed nasotracheal intubation (one) and initial airway maneuver attempted (three). In the medical subgroup, 25 of 31 patients were intubated successfully fiberoptically. All four trauma patients were intubated successfully, and all attempts were done nasally. The limitations of the technique were varied. Twenty of the 25 successful intubations had times recorded for completion (mean time, 1.8 +/- 1.4 minutes [SD]). Four of the six failed attempts had recorded times of 7.8 +/- 1.4 minutes. The mean time of the four trauma cases was 3 +/- 2.2 minutes. The presence of secretions, blood, or vomitus was the cause in five of the six failed intubations. The sixth patient kept swallowing the distal end of the scope. Fiscal restraints may also limit its use. At our institution, the financial commitment has been approximately +17,000 during the past nine years. Repair or replacement of broken equipment appears to be necessary every two or three years. Immediate airway control is often difficult with fiberoptic-aided endotracheal intubation and should be used only in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Flexible fiberoptic endoscopy for airway problems in a pediatric intensive care unit

We used flexible fiberoptic endoscopy to evaluate 87 patients with potential problems of the airway in a pediatric intensive care unit. Four different-sized bronchoscopes were used to perform 61 diagnostic laryngoscopic procedures, 35 diagnostic bronchoscopic procedures, and eight therapeutic bronchoscopic procedures. Diagnostic information was obtained in 91 of 96 procedures. Of the eight therapeutic procedures, seven were considered successful. Morbidity was minimal, and there was no death. Flexible fiberoptic endoscopy proved useful as a bedside technique for critically ill pediatric patients in whom evaluation of the airway in the operating room under general anesthesia would have been difficult.

Fibreoptic bronchoscopic nasotracheal intubation of a neonate with Pierre Robin syndrome

A case of nasotracheal intubation using a fibreoptic bronchoscope and the Seldinger technique is described. A guide wire was passed through the suction channel of the fiberscope after the epiglottis and the vocal cords were seen; the fiberscope was removed and a nasotracheal tube passed over the wire into the trachea.

Endoscopy of the airway in infants and children

We believe that many of our readers will appreciate having some familiarity with the procedures described in this manuscript. For those who have had difficulty in deciding whether the need for diagnosis justifies the risk of a procedure, this perspective will shed new light on the problem. It is appropriate to warn our readers that complete unanimity on several points is not yet evident. For example, the indications for flexible bronchoscopy, by whom the procedure should be done, and even more specific technical aspects are questions not completely resolved. However, this article is not an effort to instruct anyone in how to do the procedure. Rather, it is an effort to acquaint our readers with progress in the field. With that in mind, we are confident that the remaining questions will be answered on the basis of the training, experience, and, ultimately, the good judgment of all the physicians involved.

Anaesthetic problems in Hurler-Scheie syndrome. Report of two cases

Hurler-Scheie syndrome is an intermediate form of mucopolysaccharidosis. Affected patients characteristically present in infancy with serious abnormalities including the upper airways and the lungs. We present two patients with Hurler-Scheie syndrome and describe their anaesthetic management. One case was complicated by difficult endotracheal intubation and postoperative pneumonia. The second case was successfully managed using spinal anaesthesia and mild sedation.

Applications of an ultrathin flexible bronchoscope for neonatal and pediatric airway problems

A new 2.7 mm flexible fiberoptic bronchoscope with a directable tip was used to evaluate potential airway problems in 73 pediatric patients. Forty-eight laryngoscopies and 47 bronchoscopies were performed over an 18-month period. Persistent stridor was the most common indication for laryngoscopy; persistent wheezing, the most common indication for bronchoscopy. We obtained diagnostic information in 83 procedures, incidental findings in four, and normal results in eight. There were four complications and no deaths. This instrument enabled patients to be examined who were previously considered too small or who previously required rigid bronchoscopy under general anesthesia.

Clinical applications of ultrathin flexible bronchoscopes

Three different models of ultrathin flexible fiberoptic bronchoscopes (1.8, 2.3, and 2.7 mm in diameter) were used in 190 examinations of pediatric patients. These instruments facilitate clinical procedures and evaluations that are difficult if not impossible with previous bronchoscopes. New applications include endoscopic transnasal intubation with endotracheal tubes as small as 3.0 mm (ID), inspection of the upper lobe segments in infants weighing less than 2.5 kg, and evaluation of the lower airways through endotracheal tubes as small as 2.5 mm (ID) or tracheostomy tubes as small as no. 00 (3.1 mm ID). Although these instruments have no suction channel and are thus incapable of removing airway secretions or obtaining specimens, they are extremely useful for many clinical purposes in infants and young children.

Spelunking in the pediatric airways: explorations with the flexible fiberoptic bronchoscope

The author discusses his experience with the flexible bronchoscope, covering current instrumentation, techniques, and indications and contraindications, showing that, when used carefully by a well-trained physician, the flexible bronchoscope is a safe, relatively simple, and effective tool for exploration of the pediatric airway.

In vivo coronary angioscopy

The feasibility of in vivo coronary angioscopy was tested utilizing a 1.8 mm angioscope in vessels where blood had been replaced by optically clear liquids, including a new perfluorocarbon emulsion. After trials in postmortem canine and human coronary arteries, in vivo intraluminal visualization was accomplished in the dog with a catheterization technique and in patients during open heart surgery. The results demonstrate the feasibility and potential clinical usefulness of direct visualization of intravascular anatomy and disease, analogous to endoscopy of other organ systems.

Cricothyrotomy in the emergency department

Thirty-eight emergency cricothyrotomies were performed over a 3-year period. This was the first airway control maneuver attempted in 5 patients, 3 of whom had facial and/or neck injury, one apneic with upper airway hemorrhage, and one with aortobronchial fistula. The remaining 33 procedures were performed only after other airway management failed. Five indications were identified among these cases: 1) excessive emesis or hemorrhage (11), 2) possible cervical spine injury with airway compromise (9), 3) technical failure (7), 4) clenched teeth (5), and 5) masseter spasm following succinylcholine administration (1). Fourteen immediate complications occurred in 12 patients (32%). The most frequent was incorrect site of tracheostomy tube placement (5), with 4 of 5 misplaced through the thyrohyoid membrane. Others included execution time greater than 3 minutes (4), unsuccessful tracheostomy tube placement (3), and significant hemorrhage (2). Twelve of the 38 patients were long-term survivors. There was one long-term complication, a longitudinal fracture of the thyroid cartilage during forceful placement of an oversized tube (8 mm inner diameter) through the cricothyroid membrane. This required operative repair and left the patient with severe dysphonia.

The use of a new ultra-thin fiberoptic bronchoscope to determine endotracheal tube position in the sick newborn infant

The various techniques available for determining endotracheal tube position after intubation of a newborn are auscultation of the chest, observation of distance rings on the endotracheal tube, and chest radiology. Radiology is considered to be the most reliable method. We evaluated the use of a new ultra-thin fiberoptic bronchoscope on 20 recently intubated newborn infants to determine the position of the endotracheal tube and compared the technique with radiology. The accuracy of the two methods was comparable (correlation 0.91, P less than 0.001). Adverse changes in transcutaneous PO2 were observed during both procedures but were more marked during radiology than bronchoscopy. We conclude that the bronchoscopic technique of determining endotracheal tube position is both as safe and as accurate as radiologic technique.

Pediatric flexible bronchoscopy

We have utilized a prototype pediatric flexible bronchoscope to perform diagnostic and therapeutic procedures on pediatric patients ranging from 840 gm to 14 years of age. Flexible bronchoscopy, with appropriate instrumentation and careful attention to physiological requirements of the patient, is safe and effective in pediatric patients. The availability of new instrumentation promises to have as great an impact on pediatric pulmonology as the standard flexible bronchoscopes did on adult pulmonology. With this instrument, the indications for bronchoscopy may be considerably expanded.