Pediatric Anesthesia ISSN 1155-5645
A new twist in the pediatric difficult airway Edwardina M.M.A. Lillie1, Louise Harding2 & Mark Thomas2 1 Anaesthesia Department, Guys and St Thomas’ Hospital, London, UK 2 Anaesthesia Department, Great Ormond Street Hospital, London, UK
Keywords infant; congenital anomalies airway; difficult airway; devices techniques airway; laryngoscopes equipment; NICU critical care Correspondence Dr Edwardina M.M.A. Lillie, Anaesthesia Department, Guys and St Thomas’ Hospital, Great Maze Pond, London SE1 9RT, UK Email: [email protected]
Section Editor: David Polaner
Summary Difficult intubation of a 2.4 kg ex premature, suspected Pierre Robin Sequence with upper airway obstruction causing respiratory failure. Multiple failed intubation attempts by an experienced pediatric anesthetist using described techniques and adjuncts. A description of a simple new maneuvre using a GlideScope and a stylet. By twisting the stylet into a spiral shape, the endotracheal tube was given improved maneuverability that allowed the intubator to place the endotracheal tube tip to the glottis opening. Then by rotating the tube in a clockwise direction it could be manipulated past the vocal cords into the trachea.
Accepted 2 September 2014 doi:10.1111/pan.12538
Case report We present a case of a 2.4 kg ex premature infant, now 40 weeks postconceptional age, born by caesarian section for maternal preeclampsia and transverse lie. Pierre Robin Sequence was suspected with a small mandible and large tongue, resulting in airway obstruction requiring a nasopharyngeal airway (NPA).Despite the NPA, the patient had worsening respiratory distress and was retrieved to our neonatal intensive care unit (NICU). On arrival at the NICU, it was decided that the baby needed ventilatory support. Intubation revealed a grade 3 laryngoscopic view, and a size 3 endotracheal (ETT) was sited with difficulty. The ETT was noted to have a small leak, which increased over the next 6 h compromising ventilation, requiring increased ventilator pressures and high inspired oxygen concentrations to maintain satisfactory saturations. The ETT was upsized to reduce the leak; the NICU consultant had multiple failed intubation attempts before securing a size 3.5 ETT, confirmed by ETCO2 although the quality of the trace was variable. A chest X-ray was performed, which confirmed correct positioning of the ETT. Over the following hour, the baby developed increasing abdominal distension, despite the presence of a nasogastric tube. The NICU consultant © 2014 John Wiley & Sons Ltd
was now manually ventilating the patient with FIO2 of 1.0 on a modified Jackson Rees circuit to improve saturations. The NICU team believed the ETT was correctly positioned, reassured by the initial poor quality ETCO2 trace, and suspected a tracheoesophageal fistula (TOF) may be responsible for the gastric distension. They advanced the ETT as distal as possible into the trachea to reduce any chance of fistula ventilation. At this point the ENT and Anaesthetic teams were called to the unit with a request for transfer to theater for urgent bronchoscopy. The anesthetic registrar assessed the baby and felt they were too unstable to transfer. The registrar requested the difficult airway equipment be brought to ICU, and the anesthetic consultant on call was asked to attend. At this point, the baby’s saturations were 50% despite 100% O2 delivery and high-pressure manual ventilation. The ETCO2 trace was flat with marked abdominal distension, and the baby became bradycardic to 40 bmin 1-Cardiopulmonary Resuscitation was commenced. The ETT was removed by the consultant anesthetist and bag valve mask ventilation (BVM) started. The saturations immediately improved and the heart rate recovered after 90 s. Two person BVM ventilation was required with a guedel airway and continual aspiration of the insufflated stomach via the nasogastric 1
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Figure 1 3.5 Portex endotracheal tube twisted into a spiral/corkscrew shape using a stylet.
tube. The anesthetic consultant attempted intubation using a GlideScope that provided a good view of the anterior glottis. There was evidence of airway trauma with bleeding and marked edema, the glottic aperture only being identified by expiratory bubbles at the opening. Following 3 failed attempts at intubation using described techniques and adjuncts (1,2), the stylet was twisted into a spiral shape as shown in Figure 1. This spiral shape gave the ETT sufficient angulation to be delivered to the anterior vocal cord inlet and rotated to overcome the impingement at the glottis. Successful intubation was confirmed by auscultation and capnography. Once the tube was secured, the baby stabilized. Four days later, the infant had a microlaryngeal bronchoscopy (MLB) which showed severe supraglottic edema as a result of intubation trauma, but no evidence of a TOF. The grade of laryngoscopy at MLB was 4. A repeat MLB at 7 days postevent showed that the edema had resolved and the baby was safely extubated onto a NPA. On reflection, we suspect the intubation on ITU when the ETT was upsized, was sited correctly initially, confirmed by CO2 trace and depth on CXR, becoming dislodged later, and seated just above the larynx. This would account for the poor CO2 trace and the gastric insufflation. When the ETT was advanced to exclude a fistula it was probably advanced into the esophagus resulting in the hypoxic arrest. As the above incident, the spiral shaped stylet has been used successfully to intubate a 3-year-old child with Hurlers Syndrome. The child was presumed to have a difficult anyway, and underwent inhalational induction. BVM was possible with a guedel airway and two hands on the mask. A GlideScope provided a good view of the cords, but the angled stylet failed to pass the vocal cords. BVM was resumed. The ETT was twisted into the 2
spiral shape, and the ETT passed easily on the next attempt. There is no documented evidence of using a spiral/ corkscrew-shaped stylet to aid video assisted laryngoscopy. Wall 2 in 2010 presented a case report describing a new rotational maneuvre to achieve successful intubation in a difficult GlideScope intubation. He advocated a sharp 90° angulation of the stylet to reach the glottis, once impinging there, it is rotated 180° clockwise to enter the trachea. Kirtensen and Misuno describe tubeguiding devices delivering the tube to the laryngeal inlet, but not being able to advance the tracheal tube as the beveled tip catches on the anatomical features of the airway. They advocate the Parker Flex-Tip tracheal tube which has a centered, curved, tapered, and flexible tip with less risk of tube tip impinging on laryngeal structures thus improving intubation success in adults (3,4). In an endoscopy journal, Schembre describes using a spiral overtube in difficult colonoscopies to assist incomplete colonoscopy in patients with redundant colons, achieving successful cecal intubations in 92% of those patients (5). Different lumen, but the same principle.
1. In case of a known difficult airway, the 4th National Audit Project (Major complications of airway management in the United Kingdom Report and Findings) recommends calling for skilled assistance early and planning a difficult airway strategy. 2. If in doubt about the position of the endotracheal tube, remove it. 3. Remember the twist in the stylet when faced with a challenging intubation with an anterior larynx. Simple and effective.
Disclosures Ethical approval was not sought, as this is not a study but a case review, introducing a new maneuvre that worked practically at the hands of the authors in a desperate clinical situation. We have written consent from both parents of the patient to publish the case details. Source of funding Nil. Conflict of interest No conflicts of interest declared. © 2014 John Wiley & Sons Ltd
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References 1 Richard M. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med 2001; 56: 240–247. 2 Wall RM. A new maneuvre for endotracheal tube insertion during difficult GlideScope intubation. Emerg Med 2010; 39: 86–87.
© 2014 John Wiley & Sons Ltd
3 Mizuno J. Tracheal intubation with Parker Flex-Tip tubes assisted by tube guiding devices. Masui 2010; 59: 432–439. 4 Kirstensen M. The Parker Flex-Tip tube versus a standard tube for fibreoptic orotracheal intubation: a randomized double-blind study. Anesthesiology 2003; 98: 354–358.
5 Schembre D. Spiral overtube-assisted colonoscopy after incomplete colonoscopy in the redundant colon. Gastrointest Endosc 2011; 73: 515–519.