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Year : 2012  |  Volume : 3  |  Issue : 3  |  Page : 180-182

Nasal fiberoptic intubation: A savior during handling a pediatric difficult airway

Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication29-Apr-2013

Correspondence Address:
Sunny Malik
Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-6944.111189

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We report a case of successful intubation via fiberoptic bronchoscope in a pediatric patient with a friable carcinoma oral cavity including the neck region posing difficulty in airway management. Out of the available airway devices from the basic MacIntosh laryngoscope to videolaryngoscopes to the life-saving surgical airway techniques, fiberoptic Intubation still remains to be the most successful method in experienced hands during handling of pediatric difficult airway.

Keywords: Awake nasal intubation, fibreoptic bronchoscope, paediatric difficult airway

How to cite this article:
Malik S, Dubey M, Batra V, Naithani B K. Nasal fiberoptic intubation: A savior during handling a pediatric difficult airway. Indian J Oral Sci 2012;3:180-2

How to cite this URL:
Malik S, Dubey M, Batra V, Naithani B K. Nasal fiberoptic intubation: A savior during handling a pediatric difficult airway. Indian J Oral Sci [serial online] 2012 [cited 2019 Nov 20];3:180-2. Available from: http://www.indjos.com/text.asp?2012/3/3/180/111189

  Introduction Top

Carcinoma of the face and head and neck region poses a great airway problem for the anesthesiologist on a usual basis. In the pediatric age group, the most common are oral hemangiomas accounting for 14%, thus posing difficulty in airway management along with possibility of hemorrhagic losses. [1] Loss of airway under muscle relaxation, difficulty to intubate, difficulty to ventilate, and unwillingness to awake intubation in the pediatric age group makes such cases the most challenging ones. [2] According to American Society of Anesthesiologist difficult airway algorithm awake intubation devices used in the recent past include: Direct laryngoscopy and intubation, blind nasal/oral intubation, fiberoptic intubation, intubating Laryngeal Mask Airway assisted intubation, trachlight intubation and retrograde intubation or percutaneous dilatation tracheostomy.

Out of these awake fiberoptic intubation remains the safest and most effective methods in the experienced hands. [3],[4] We report a case of fiberoptic-guided nasal intubation in a spontaneously breathing pediatric patient under topical anesthesia with an anticipated difficult airway.

  Case Report Top

A 16-year-old female child weighing 32 kg presented with complaints of progressively increasing swelling involving the left cheek and the neck [Figure 1]. The patient was scheduled for an excisional biopsy. The positive pre anesthetic check-up findings suggesting a difficult airway included:

  • Disrupted oral cavity
  • 2 finger mouth opening
  • A vertically placed tongue [Figure 2]
  • Restricted neck extension
  • A fragile overhanging mucosa inside the oral cavity as per history of previous oral bleeds
  • Non-assessibility of Mallampati Grade
  • Pediatric age group
  • Difficult access for surgical cricothyrotomy
Figure 1: Mass involving cheek and neck

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Figure 2: Difficult airway showing friable mass with vertically displaced tongue

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The patient was pre-medicated as per the standard protocol without any oral sedatives. The patient was counseled for awake fiberoptic intubation. A difficult airway cart was kept ready and the procedure was done under the expert guidance of an experienced anesthesiologist with expertise in blind nasal intubation. Intravenous line was secured and standard monitoring aids (pulse oximeter, non-invasive blood pressure, electrocardiogram, and capnography) applied. 0.2 mg glycopyrolate was given intravenously (i.v.) to prevent secretions. The child was nebulized with 4% lignocaine (5 ml) and nostrils were prepared with nasal pack instilled with 4% lignocaine after application of 0.01% xylometazoline drops. 0.5 mg midazolam and 20 microgram fentanyl i.v. were given as sedation to reduce the anxiety of procedure. Pediatric fiberoptic bronchoscopy was prepared by railroading 6 mm internal diameter pre-warmed endotracheal tube (ET tube). After removing the nasal packs, fiberoptic bronchoscopy was done and the glottis opening appreciated. So, supraglottic airway was anesthetized with nebulized 4% lignocaine and supplemented by 2% lignocaine given by "Spray as you go", i.e., SAYGO technique. The ET tube was inserted, connected with the breathing circuit, and the position of ET tube confirmed through capnography as well as five point auscultation. The patient was then anesthetized with Propofol (1.5 mg/kg) and atracurium (0.5 mg/kg) and maintained with N2O: O2 in a 50:50 with sevoflurane. At the end of the procedure, anesthesia was reversed with neostigmine and glycopyrolate. The ET tube was r tained and Oxygen via T-piece was supplemented. The patient was extubated the next day.

  Discussion Top

Pediatric patients with maxillofacial head and neck tumors pose a great challenge to an anesthesiologist for securing the airway. The incidence of difficult intubation has been shown to be higher in ENT cancer patients than general surgery patients (12.3% vs. 2.0%). [5]

A variety of airway devices (LMA, P-LMA, I-LMA), Trachlight, Videolaryngoscopes (Airtraq, Truview, Glidescope) and the fiberoptic bronchoscope which is known to be gold standard have been used for awake intubation in anticipated difficult intubation scenarios.

LMA designed by Dr. Archie Bain in 1981 had been used by Jukka Rasanen under inhalational induction with spontaneous breathing and doing fiberoptic intubation through it using two ET tubes (second one smaller to hold the original tube in place as LMA is withdrawn). [6] LMA has also been mentioned as the first alternative device in ASA unanticipated difficult intubation condition. However, as the mouth opening was two finger with a vertically placed tongue, it was not possible to insert the LMA. Moreover, the protruding tumor inside the oral cavity made the placement of LMA in the pyriform fossa and hypopharynx highly difficult causing trauma and bleeding from tumor.

Trachlight is a substitute to Fibre optic bronchoscopy and is based on the principle of transillumination used for both oral and nasal intubation in distorted airway. Mi kyung et al. successfully intubated a 6-year-old girl, post chemotherapy with a huge fibrosarcoma of the hard palate under spontaneous breathing with 100% oxygen in sevoflurane mixture which was increased % by % to vol%. [7] In our case, trachlight was not a good option due to fear of bleeding from the friable tumor mass and it was very difficult to appreciate the transillumination through the bulky neck mass.

Various modifications of direct laryngoscopy and intubation have been tried for difficult airway with maneuvers like Backward Upward Rightward Pressure, Optimal External Laryngeal Manipulation or lateral cheek retraction and using videolaryngoscopes such as Truview, Airtraq, Glidescope, Storz videolaryngoscope etc., showing proven advantages of easy and simple operation, excellent laryngeal view, less cervical movements and easy learning curves. [8] But, all these airway devices cannot be used in restricted mouth opening and the vertically placed tongue was assumed difficult to sweep into the non-compliant submandibular space whose appreciation was rather more complicated.

Tracheostomy under local anesthesia has been considered the "definitive modality" of airway management in situations such as deep neck infections, [9] but it was kept as a last resort in our case due to the anatomical distortion of the anterior neck as result of a firm swelling.

Awake FOI whether done in sitting [4] or supine position is the most valuable method of securing the airway in anticipated difficult-to-intubate conditions. Awake Fibreoptic Intubation is done using various techniques like superior laryngeal and transtracheal block, conscious sedation with midazolam, fentanyl or low-dose ketamine, [10] and the combined technique of 10% lignocaine spray on the post pharyngeal wall with local anesthetic nebulization adding on a "Spray as you go" technique which was utilized in our case.

Maintaining spontaneous respiration using fiberoptic intubation is the key point during management of anticipated difficult airway. Patients' co-operation, proper patient preparation (including psychological preparation) and adequate training in FOB can convert a difficult-to-handle situation to an easy one thus reducing the mortality occurring from loss of an already compromised airway in patients like deep neck infections, enlarging neck mass, and distorted oral cavity.

  References Top

1.Chiller KG, Passaro D, Frieden IJ. Hemangiomas of infancy: Clinical characteristics, morphologic subtypes, and their relationship to race, ethnicity, and sex. Arch Dermatol 2002;138:1567-76.  Back to cited text no. 1
2.Raval C, Rashiduddin M. Nasal endotracheal intubation under fibreoptic endoscopic control in difficult oral intubation, two pediatric cases of submandibular abscess. Oman Med J 2009;24:51-3.  Back to cited text no. 2
3.Khan RM. Local anesthesia and sedation regime for awake intubation. In: Khan RM, Maroof M, editors. Airway Management. 4 th ed. Hyderabad: Paras Medical Publisher; 2011. p. 147-50.  Back to cited text no. 3
4.Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, et al. A rapidly enlarging neck mass: The role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627-9.  Back to cited text no. 4
5.Arné J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, et al. Preoperative assessment for difficult intubation in general and ENT surgery: Predictive value of a clinical multivariate risk index. Br J Anaesth 1998;80:140-6.  Back to cited text no. 5
6.Rasanen J. The laryngeal mask airway: First class on difficult airways. Finnanest 2000;33:302-5.  Back to cited text no. 6
7.Kim MK, Lee BD, Kang WJ. Trachlight-guided nasotracheal intubation in a pediatric patient with oral fibrosarcoma. J Kyung Hee Univ Med Cent 2011;27:56-9.  Back to cited text no. 7
8.Amir SH, Ali QE, Firdaus U, Azhar AZ. Lateral cheek retraction: A simple maneuver in aiding laryngoscopy and intubation in paediatric patients. J Rom Anest Terap Int 2012;19:35-8.  Back to cited text no. 8
9.Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: A case series and review of the literature. Anesth Analg 2005;100:585-9.  Back to cited text no. 9
10.Bangaari A, Nair T. Management of difficult airway. Awake and under anaesthesia. Indian J Anaesth 2012;56:210-1.  Back to cited text no. 10
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