Fiberoptic Bronchoscopy-Assisted Nasotracheal Intubation in an Emergent Difficult Pediatric Airway Maintained by Supraglottic Airway Device

To the Editor:

Pierre Robin malformation is associated with difficult airway. It is very difficult to make a seal for effective facemask ventilation in small infants with this condition.[1] Securing such an airway and intubation poses a challenge as an elective procedure, even more so in an emergent situation.

A 1-month-old male baby, weight 2 kg presented with acute onset respiratory distress following milk feed. The baby had cleft palate, micrognathia, glossoptosis, and had experienced feeding difficulties right from birth, leading to recurrent chest infections and failure to thrive (birth weight 3 kg). There were no other associated abnormalities. On admission to intensive care unit, baby was tachycardic (heart rate 190/min), tachypnoeic (respiratory rate 90/min), and spO2 70%. After airway clearance, trial of oxygen and nasopharyngeal continuous positive airway pressure (CPAP) were given but failed. Due to persisting desaturation, bag mask ventilation was attempted. Saturation improved to 85 to 90% with difficulty. Effective seal could not be created due to micrognathia, and improvement in saturation was not consistent. Direct (with Miller and Macintosh blade) and video laryngoscopy with awake intubation was attempted; however, vocal cords could not be visualized. Desaturation continued and worsened; hence, it was abandoned. At this point, awake insertion of supraglottic airway was done and assisted ventilation was given. Oxygenation improved and was consistently maintained with this method. Flexible fiberoptic bronchoscopy (FOB)-assisted intubation was planned and sevoflurane was used to maintain adequate anesthesia depth during the procedure. Cuffed 3.5 size endotracheal tube was preloaded onto flexible fiberoptic bronchoscope (2.8 mm), which was inserted nasally. When the tip of scope was advanced into the supraglottic area, i-gel was partially withdrawn and the scope navigated into the trachea, under video screen visualization. The endotracheal tube was subsequently rail-roaded over the scope and secured. Visualized trachea up to the carina was normal. The patient was stabilized on invasive ventilation for next 2 days. Chest radiograph revealed right lung atelectasis which subsequently expanded. Tongue–lip adhesion was performed. Subsequently, he was extubated successfully to nasopharyngeal CPAP.

A difficult-to-ventilate difficult-to-intubate airway is a clinician's nightmare, especially in the small-sized infant. When direct laryngoscopy fails, numerous methods have been tried and described to gain airway control. These include use of video laryngoscopes, blind nasal intubation, and nasal/oral fiberoptic intubation. These techniques are challenging and nearly impossible in the nonsedated, noncooperative patient. In such scenarios, in older children and adults, intubation using laryngeal mask airway (LMA) as a conduit for FOB-assisted intubation has been found to be a reliable technique.[2] [3] However, endotracheal tube dislodgement during withdrawal of LMA can occur as a complication, especially in pediatric patients.[4] Additionally, in our case, owing to small size of the infant, we used size 1 i-gel whose inner diameter was too small to allow passage of 3.5 sized endotracheal tube through it. Hence, using the i-gel as a conduit for FOB was not feasible. In a small infant with difficult-to-ventilate difficult-to-intubate airway, we believe our technique of sequential Supraglottic Airway followed by Nasal FOB-guided Tube-insertion for difficult Airway (S.A.N.T.A.) can be an effective solution. The airway rescue technique used is illustrated in [Fig. 1], which shows the step-by-step components recreated in the laboratory on a mannequin. It has several advantages. The i-gel cuff acts as a hook, which creates more pharyngeal space for easy meandering of the FOB. Also, oxygenation and ventilation can be maintained well while the nasal FOB insertion occurs. This technique can be used routinely in patients where intubating LMA is not available. Its utility is, however, limited to those patients who have an adequate degree of mouth opening to allow supraglottic insertion and do not have any contraindication for nasal intubation (such as choanal atresia, coagulopathy, or skull fracture).

Fig. 1 Steps for Supraglottic Airway followed by Nasal FOB-guided Tube-insertion for difficult Airway (S.A.N.T.A.) rescue: (A) Insert supraglottic airway (laryngeal mask airway [LMA]/i-gel) and provide positive breaths. (B) Thread endotracheal tube onto fiberoptic bronchoscope. (C) Nasal insertion of bronchoscope till the cuff of supraglottic device is seen in bronchoscopic view. (D) Supraglottic device is deflated and partially withdrawn; glottis is visualized. (E) Bronchoscope is passed through glottis into trachea. This is followed by rail-roading of endotracheal tube. (F) Nasotracheal tube confirmed in trachea (by chest rise and capnography) and secure. Then, supraglottic device is completely removed.

Publication History

Received: 14 August 2023

Accepted: 20 December 2023

Article published online:
19 February 2024

• References

• 1 Li WY, Poon A, Courtemanche D. et al. Airway management in Pierre Robin sequence: the Vancouver Classification. Plast Surg (Oakv) 2017; 25 (01) 14-20
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• 4 Muraika L, Heyman JS, Shevchenko Y. Fiberoptic tracheal intubation through a laryngeal mask airway in a child with Treacher Collins syndrome. Anesth Analg 2003; 97 (05) 1298-1299