Management of the Difficult Pediatric Airway in an Austere Environment Using the Lightwand
Donald J. Fox, MD, * Michael D. Matson, MDT Anesthesia and Operative Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX.
Increasingly, medical teams are providing sophisticated surgical treatment to pediatric patients in developing nations. Such care is often administered under relatively austere conditions using easily transported equipment. Because some of these patients may present with congenital or acquired airway abnormalities that make direct laryngoscopy difficult or impossible, alternative methodsof endotrachealintubationshould be available. One such technique Zs lightwand-guided endotracheal intubation. Use of the lightwand has a proven record of success and obviates the need for the heavier, more delicate, and more expensive flexible fiber-optic laryngoscope or pediatric bronchoscope. Two cases are reported in which pediatric patients with difficult airway anatomy due to severe burn scar contractures were successfully and easily intubated using the lightwand. This technique is useful for manage*Staff Anesthesiologist tSenior Resident Address reprint requests to Dr. Fox at the Anesthesia and Operative Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
ment of the difficult pediatric airway in the austere ronment of the typical medical relief mission. Keywords:
endotracheal,
envi-
Anesthesia, intratracheal; intubation, pediatrics; airway; trachea.
Introduction The authors were recently participants in a U.S. Armysponsored humanitarian medical mission to Central America. Their team provided anesthesia care to a large number of children undergoing plastic and reconstructive surgical procedures. A great number of these patients presented with severe burn scar contractures requiring excision and grafting. All surgery was performed at a civilian regional hospital; this facility provided an anesthesia machine. All other anesthesia equipment, including monitors, was transported. Standard airway management equipment for adult and pediatric patients, as well as a lightwand (Tube-Stat, Concept, Inc., Clearwater, FL), were included in the supplies, but fiber-optic laryngoscopy and bronchoscopy were not available. The need to travel light limited the size, complexity, and delicacy of the anesthesia equipment available.
Case Reports
Received for publication May 9, 1989; revised manuscript accepted for publication July 10, 1989.
Case 1
0 1990 Butterworth
An &year-old female was scheduled for surgical release of burn scars to the neck and left axilla. Past
Publishers
J. Clin. Anesth.,
vol. 2, March/April
1990
123
Case Reports
medical history was unremarkable, with the exception of full thickness burns to the neck and left axilla during early childhood. At age 7, she underwent an excision and grafting procedure. At that time, her trachea was intubated under direct laryngoscopy, but only with great difficulty and after multiple attempts. There was no history of upper airway obstructive symptoms. Upon physical exam, she weighed 19 kg and was noted to have severe burn scar contractures to the left axilla and anterior neck. Her mandible was firmly fixed to the chest by contracted scar. She was able to open her mouth 3.5 to 4.0 cm by extending the neck at the atlanto-occipital joint but was unable to achieve cervical extension beyond this point. Because of the patient’s difficult airway anatomy, plans were made to intubate her trachea using the lightwand. The connector was removed from a 5.5 mm endotracheal tube, and the lightwand was lubricated and inserted in the same manner as a stylet. The distal 4 cm of the endotracheal tube/lightwand combination was bent into a hockey-stick configuration. The surgeons were prepared to perform an emergent release of the contracture to allow direct visualization of the larynx if intubation was unsuccessful. The patient was not premeditated. She was brought to the operating room, and monitors, including a precordial stethoscope, electrocardiogram (EKG), pulse oximeter, and Dinamap blood pressure monitor (Critikon, Inc., Tampa, FL), were put in place. Anesthesia was induced by mask with halothane, nitrous oxide, and oxygen. Spontaneous breathing was maintained, and no adjunctive devices were necessary for airway patency. Intravenous (IV) access was secured and nitrous oxide discontinued. Under deep halothane anesthesia (2.5% inspired concentration), a 5.5 mm endotracheal tube was passed into the trachea over the lightwand. Despite the thick scar tissue over the trachea and an inability to dim the operating room lights, a distinct cherry red glow was easily recognized when the trachea was transilluminated. Only one attempt was required; the elapsed time from placing the lightwand in the mouth to confirming bilateral breath sounds was less than 20 seconds. The remainder of the case proceeded uneventfully, and the patient was extubated without incident.
Case2 The patient was a lo-year-old male, weighing 24 kg and presenting with severe burn scars of the face. Contractures secondary to these burns prevented closing of the eyelids bilaterally, and he was scheduled for bilateral lower lid skin grafts. Medical history was 124
J. Clin. Anesth., vol. 2, March/April
1990
unremarkable with the exception of second-degree and full-thickness burns sustained in early childhood, involving the upper chest, neck, and face. He had a history of multiple skin grafting procedures under general anesthesia several years prior to this hospitalization, without complication. Physical exam was remarkable only for severe burn scars over the upper chest, neck, and face. There was no contracture of the neck, and he had relatively normal cervical range of motion. The facial scarring was uniform and confluent. Mandibular excursion was limited by a contracted scar about the oral aperture. The maximum diameter of his fully opened mouth was 3 cm, with intact dentition. Because this patient had a small and inelastic mouth, we planned for tracheal intubation using a lightwand technique. A 6.0 mm oral RAE endotracheal tube (Mallinckrodt, Argyle, NY) was styletted with the lightwand, and the distal 4 cm was bent into a hockeystick configuration. ‘I’he patient was brought to the operating room and monitored with a precordial stethoscope, EKG, pulse oximeter, Dinamap blood pressure monitor, and axillary temperature probe. Anesthesia was induced with halothane, nitrous oxide, and oxygen, and IV access was secured. Under deep halothane/oxygen anesthesia (2.5%) inspired concentration) with spontaneous ventilation, the endotracheal tube was easily passed over the lightwand. The trachea was intubated on the first attempt, in less than 20 seconds. The remainder of the anesthetic course was uneventful, and the patient was extubated without incident.
Discussion The austere environment of the typical medical missionary hospital imposes obvious limitations on the practice of modern anesthesia. Two examples of pediatric patients with difficult airways have been presented, both managed with lightwand endotracheal intubation. While this method is gradually gaining wider acceptance in the United States, many practitioners in U.S. hospitals would elect to perform fiberoptic intubations on such patients.’ Use of the lighted stylet for endotracheal intubation was first described in the 195Os,?J but the technique has probably not been used by most practicing anesthesiologists. The lightwand has recently been evaluated in detail and compared with both direct laryngoscopic and blind nasal intubation techniques.“.” In these studies, the lighted stylet was found to be comparable to direct laryngoscopy and superior to blind nasal endotracheal intubation techniques with
Lightwand
respect to speed, efficacy, and frequency of complications. The lightwand was found to be particularly useful in patients having difficult airway anatomy.4.6 Two studies observed that minimal or no movement of the cervical spine is necessary for lightwand-guided oral endotracheal intubation.4,5 One study reported success in 30 of 31 lightwand intubations in children with abnormal upper airways.” These airway abnormalities ranged from various craniofacial anomalies to cervical spine immobility or instability. One patient could not be intubated with the lightwand, and attempts at fiber-optic intubation also were unsuccessful. The authors frequently use the lightwand technique in patients with normal or abnormal upper airway anatomy. Their experience is consistent with published reports in which missed tracheal intubations are rare when using the lighted stylet.5,6 This high degree of success was maintained during the authors’ Central American mission. In addition to the two pediatric patients reported here, several adult patients with normal upper airways were intubated using the lightwand. Every patient was intubated on the first attemnt. The lightwand technique has several advantages:
and the difficult pediatric air-may: Fox and Matson
the lighted stylet facilitates use with smaller tubes. This 5.5 mm internal diameter size limitation tends to restrict the use of the technique to children 5 years of age and older, since the lightwand cannot be accommodated in a tube any smaller in diameter than 5.5 mm. Anesthetic practice during this medical mission was consistent with U.S. standards with respect to monitoring and anesthetic technique. This practice was in large part due to the availability of excellent portable monitors. However, space, weight, and cost constraints imposed limits on the equipment inventory. Transportation of medical teams and supplies to underdeveloped areas of the world requires the use of the simplest and most portable equipment compatible with U.S. standards of practice. The lightwand method of guided endotracheal intubation is well suited to medical relief missions because of the austere environment in which they occur. By logical extension, the technique also should be useful in combat support hospitals for management of difficult airways in wartime casualties.
References 1. It is technically simple in terms of both equipment and practice. 2. It is inexpensive and very compact. 3. Blood and/or secretions in the oropharynx do not interfere with the use of the lightwand as they might with fiber-optic intubation. 4. It is easily mastered and taught to others. 5. Aside from thorough cleaning between cases, no routine care or maintenance is necessary. 6. Poor ambient light enhances the technique, but it is not necessary to dim the lights for success, as demonstrated in this report. The only important shortcoming of the lightwand technique is the size of the endotracheal tube that can be used. An endotracheal tube of 5.5 mm internal diameter is the smallest that can be passed with this instrument. Removing the connector and lubricating
1. Ovassapian A, Dykes MH: Difficult pediatric intubation-an indication for the fiberoptic bronchoscope. Anesthesiology 1982;56:412-3. R, Richards H: Illuminated introducer for 2. Macintosh endotracheal tubes. Anaesthesia 1957; I2:223-5. 3. Berman RA: Lighted stylet [Current Comment]. AnesthesioloRy 1959;20:382-3. 4. Fox DJ, Castro T, Rastrelli AJ: A comparison of intubation techniques in the awake patient: the Flexi-lum surgical light (lightwand) uersuS blind nasal approach. Anesthesiology 1987;66:69-7 1. 5. Ellis DC, Jakymec A, Kaplan RM, et al: Guided orotracheal intubation in the operating room using a lighted stylet: a comparison with the direct laryngoscopic technique. Anesthesiology 1986;64:823-6. 6. Holzman RS, Nargozian CD, Florence FB: Lightwand intubation in children with abnormal upper airways. Anesthesiology 1988;69:784-7.
J. Clin. Anesth.,
vol. 2, March/April
1990
125
Donald J. Fox, MD, * Michael D. Matson, MDT Anesthesia and Operative Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX.
Increasingly, medical teams are providing sophisticated surgical treatment to pediatric patients in developing nations. Such care is often administered under relatively austere conditions using easily transported equipment. Because some of these patients may present with congenital or acquired airway abnormalities that make direct laryngoscopy difficult or impossible, alternative methodsof endotrachealintubationshould be available. One such technique Zs lightwand-guided endotracheal intubation. Use of the lightwand has a proven record of success and obviates the need for the heavier, more delicate, and more expensive flexible fiber-optic laryngoscope or pediatric bronchoscope. Two cases are reported in which pediatric patients with difficult airway anatomy due to severe burn scar contractures were successfully and easily intubated using the lightwand. This technique is useful for manage*Staff Anesthesiologist tSenior Resident Address reprint requests to Dr. Fox at the Anesthesia and Operative Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
ment of the difficult pediatric airway in the austere ronment of the typical medical relief mission. Keywords:
endotracheal,
envi-
Anesthesia, intratracheal; intubation, pediatrics; airway; trachea.
Introduction The authors were recently participants in a U.S. Armysponsored humanitarian medical mission to Central America. Their team provided anesthesia care to a large number of children undergoing plastic and reconstructive surgical procedures. A great number of these patients presented with severe burn scar contractures requiring excision and grafting. All surgery was performed at a civilian regional hospital; this facility provided an anesthesia machine. All other anesthesia equipment, including monitors, was transported. Standard airway management equipment for adult and pediatric patients, as well as a lightwand (Tube-Stat, Concept, Inc., Clearwater, FL), were included in the supplies, but fiber-optic laryngoscopy and bronchoscopy were not available. The need to travel light limited the size, complexity, and delicacy of the anesthesia equipment available.
Case Reports
Received for publication May 9, 1989; revised manuscript accepted for publication July 10, 1989.
Case 1
0 1990 Butterworth
An &year-old female was scheduled for surgical release of burn scars to the neck and left axilla. Past
Publishers
J. Clin. Anesth.,
vol. 2, March/April
1990
123
Case Reports
medical history was unremarkable, with the exception of full thickness burns to the neck and left axilla during early childhood. At age 7, she underwent an excision and grafting procedure. At that time, her trachea was intubated under direct laryngoscopy, but only with great difficulty and after multiple attempts. There was no history of upper airway obstructive symptoms. Upon physical exam, she weighed 19 kg and was noted to have severe burn scar contractures to the left axilla and anterior neck. Her mandible was firmly fixed to the chest by contracted scar. She was able to open her mouth 3.5 to 4.0 cm by extending the neck at the atlanto-occipital joint but was unable to achieve cervical extension beyond this point. Because of the patient’s difficult airway anatomy, plans were made to intubate her trachea using the lightwand. The connector was removed from a 5.5 mm endotracheal tube, and the lightwand was lubricated and inserted in the same manner as a stylet. The distal 4 cm of the endotracheal tube/lightwand combination was bent into a hockey-stick configuration. The surgeons were prepared to perform an emergent release of the contracture to allow direct visualization of the larynx if intubation was unsuccessful. The patient was not premeditated. She was brought to the operating room, and monitors, including a precordial stethoscope, electrocardiogram (EKG), pulse oximeter, and Dinamap blood pressure monitor (Critikon, Inc., Tampa, FL), were put in place. Anesthesia was induced by mask with halothane, nitrous oxide, and oxygen. Spontaneous breathing was maintained, and no adjunctive devices were necessary for airway patency. Intravenous (IV) access was secured and nitrous oxide discontinued. Under deep halothane anesthesia (2.5% inspired concentration), a 5.5 mm endotracheal tube was passed into the trachea over the lightwand. Despite the thick scar tissue over the trachea and an inability to dim the operating room lights, a distinct cherry red glow was easily recognized when the trachea was transilluminated. Only one attempt was required; the elapsed time from placing the lightwand in the mouth to confirming bilateral breath sounds was less than 20 seconds. The remainder of the case proceeded uneventfully, and the patient was extubated without incident.
Case2 The patient was a lo-year-old male, weighing 24 kg and presenting with severe burn scars of the face. Contractures secondary to these burns prevented closing of the eyelids bilaterally, and he was scheduled for bilateral lower lid skin grafts. Medical history was 124
J. Clin. Anesth., vol. 2, March/April
1990
unremarkable with the exception of second-degree and full-thickness burns sustained in early childhood, involving the upper chest, neck, and face. He had a history of multiple skin grafting procedures under general anesthesia several years prior to this hospitalization, without complication. Physical exam was remarkable only for severe burn scars over the upper chest, neck, and face. There was no contracture of the neck, and he had relatively normal cervical range of motion. The facial scarring was uniform and confluent. Mandibular excursion was limited by a contracted scar about the oral aperture. The maximum diameter of his fully opened mouth was 3 cm, with intact dentition. Because this patient had a small and inelastic mouth, we planned for tracheal intubation using a lightwand technique. A 6.0 mm oral RAE endotracheal tube (Mallinckrodt, Argyle, NY) was styletted with the lightwand, and the distal 4 cm was bent into a hockeystick configuration. ‘I’he patient was brought to the operating room and monitored with a precordial stethoscope, EKG, pulse oximeter, Dinamap blood pressure monitor, and axillary temperature probe. Anesthesia was induced with halothane, nitrous oxide, and oxygen, and IV access was secured. Under deep halothane/oxygen anesthesia (2.5%) inspired concentration) with spontaneous ventilation, the endotracheal tube was easily passed over the lightwand. The trachea was intubated on the first attempt, in less than 20 seconds. The remainder of the anesthetic course was uneventful, and the patient was extubated without incident.
Discussion The austere environment of the typical medical missionary hospital imposes obvious limitations on the practice of modern anesthesia. Two examples of pediatric patients with difficult airways have been presented, both managed with lightwand endotracheal intubation. While this method is gradually gaining wider acceptance in the United States, many practitioners in U.S. hospitals would elect to perform fiberoptic intubations on such patients.’ Use of the lighted stylet for endotracheal intubation was first described in the 195Os,?J but the technique has probably not been used by most practicing anesthesiologists. The lightwand has recently been evaluated in detail and compared with both direct laryngoscopic and blind nasal intubation techniques.“.” In these studies, the lighted stylet was found to be comparable to direct laryngoscopy and superior to blind nasal endotracheal intubation techniques with
Lightwand
respect to speed, efficacy, and frequency of complications. The lightwand was found to be particularly useful in patients having difficult airway anatomy.4.6 Two studies observed that minimal or no movement of the cervical spine is necessary for lightwand-guided oral endotracheal intubation.4,5 One study reported success in 30 of 31 lightwand intubations in children with abnormal upper airways.” These airway abnormalities ranged from various craniofacial anomalies to cervical spine immobility or instability. One patient could not be intubated with the lightwand, and attempts at fiber-optic intubation also were unsuccessful. The authors frequently use the lightwand technique in patients with normal or abnormal upper airway anatomy. Their experience is consistent with published reports in which missed tracheal intubations are rare when using the lighted stylet.5,6 This high degree of success was maintained during the authors’ Central American mission. In addition to the two pediatric patients reported here, several adult patients with normal upper airways were intubated using the lightwand. Every patient was intubated on the first attemnt. The lightwand technique has several advantages:
and the difficult pediatric air-may: Fox and Matson
the lighted stylet facilitates use with smaller tubes. This 5.5 mm internal diameter size limitation tends to restrict the use of the technique to children 5 years of age and older, since the lightwand cannot be accommodated in a tube any smaller in diameter than 5.5 mm. Anesthetic practice during this medical mission was consistent with U.S. standards with respect to monitoring and anesthetic technique. This practice was in large part due to the availability of excellent portable monitors. However, space, weight, and cost constraints imposed limits on the equipment inventory. Transportation of medical teams and supplies to underdeveloped areas of the world requires the use of the simplest and most portable equipment compatible with U.S. standards of practice. The lightwand method of guided endotracheal intubation is well suited to medical relief missions because of the austere environment in which they occur. By logical extension, the technique also should be useful in combat support hospitals for management of difficult airways in wartime casualties.
References 1. It is technically simple in terms of both equipment and practice. 2. It is inexpensive and very compact. 3. Blood and/or secretions in the oropharynx do not interfere with the use of the lightwand as they might with fiber-optic intubation. 4. It is easily mastered and taught to others. 5. Aside from thorough cleaning between cases, no routine care or maintenance is necessary. 6. Poor ambient light enhances the technique, but it is not necessary to dim the lights for success, as demonstrated in this report. The only important shortcoming of the lightwand technique is the size of the endotracheal tube that can be used. An endotracheal tube of 5.5 mm internal diameter is the smallest that can be passed with this instrument. Removing the connector and lubricating
1. Ovassapian A, Dykes MH: Difficult pediatric intubation-an indication for the fiberoptic bronchoscope. Anesthesiology 1982;56:412-3. R, Richards H: Illuminated introducer for 2. Macintosh endotracheal tubes. Anaesthesia 1957; I2:223-5. 3. Berman RA: Lighted stylet [Current Comment]. AnesthesioloRy 1959;20:382-3. 4. Fox DJ, Castro T, Rastrelli AJ: A comparison of intubation techniques in the awake patient: the Flexi-lum surgical light (lightwand) uersuS blind nasal approach. Anesthesiology 1987;66:69-7 1. 5. Ellis DC, Jakymec A, Kaplan RM, et al: Guided orotracheal intubation in the operating room using a lighted stylet: a comparison with the direct laryngoscopic technique. Anesthesiology 1986;64:823-6. 6. Holzman RS, Nargozian CD, Florence FB: Lightwand intubation in children with abnormal upper airways. Anesthesiology 1988;69:784-7.
J. Clin. Anesth.,
vol. 2, March/April
1990
125
