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Anesth Analg 2003;97:1298-1299
© 2003 International Anesthesia Research Society

PEDIATRIC ANESTHESIA

Fiberoptic Tracheal Intubation Through a Laryngeal Mask Airway in a Child with Treacher Collins Syndrome

Lisa Muraika, DO*, Julius S. Heyman, MD PhD{dagger}, and Yuri Shevchenko, MD*

Departments of Anesthesiology, *St. Christopher’s Hospital for Children, Philadelphia; and {dagger}Chester County Hospital, West Chester, Pennsylvania

Address correspondence and reprint requests to Lisa Muraika, DO, St. Christopher’s Hospital for Children, Erie Ave. at Front St., Philadelphia, PA 19134. Address e-mail to lmuraika_2000{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Discussion
 References
 

IMPLICATIONS: The laryngeal mask airway reliably provides a patent airway in children with potentially difficult and normal airways. We additionally describe its utility as a conduit for fiberoptic intubation of the trachea, specifically, in a child with Treacher Collins syndrome.


   Introduction
Top
 Abstract
 Introduction
Discussion
 References
 
Treacher Collins syndrome (TCS) is a rare, inherited condition and can present one of the most difficult airways encountered by an anesthesiologist. Because children with TCS can have many craniofacial abnormalities, they often require a variety of corrective surgical procedures, thus confronting the anesthesiologist with a possibly difficult intubation (1,2). Below, we describe the anesthetic management of a 3 1/2-yr-old girl with TCS who presented for surgical repair of a cleft palate. Her medical history was significant for prematurity (36 wk gestation), gastroesophageal reflux disease, tracheoesophageal fistula, atrial septal defect, and apnea. Her surgical history included correction of the tracheoesophageal fistula, atrial septal defect, and a Nissen fundoplication. No records of previous anesthetics were available because these surgeries were performed in Russia.

Standard monitors were applied in the operating room, a 22-gauge IV was placed while the child received 50% O2 and 50% N2O via face mask. Atropine 0.2 mg was administered IV. Inhaled induction of general anesthesia was performed with 8% sevoflurane in a N2O/O2 mixture. After confirming that the lungs could be manually ventilated with bag and mask, 7 mg of rocuronium was given IV. Sevoflurane was reduced to 2% and the patient was placed on 100% fraction of inspired oxygen. Direct laryngoscopy with both the Macintosh and Miller blades failed to reveal the vocal cords. Furthermore, we were unable to intubate the trachea with a light wand. Fiberoptic intubation was extremely difficult secondary to a large, posterior tongue and very limited mouth opening. As mask and bag ventilation became more difficult, a #2 laryngeal mask airway (LMA) was placed and the patient was ventilated manually. We finally succeeded in intubating the patient in the following manner. We connected two 4.5-mm uncuffed endotracheal tubes (ETT) together in an end-to-end configuration by using a cut ETT connector as a female-to-female adapter (Fig. 1). A fiberoptic bronchoscope was threaded through the two ETTs and introduced into the lumen of the LMA via a swivel connector. The vocal cords were easily visualized, and the ETT assembly was advanced into the trachea. The bronchoscope and LMA were then removed. The female-to-female adapter was disconnected from two ETTs and replaced with a standard tube connector. The ETT was connected to our circuit and end-tidal carbon dioxide and bilateral breath sounds were confirmed. The surgery was eventually aborted, however, secondary to inadequate palate exposure from decreased mouth opening. Neuromuscular blockade was reversed and the patient was tracheally extubated without incident.



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  		Figure 1. Fiberoptic scope loaded with two endotracheal tubes (ETTs) fastened with a cut ETT connector and placed through a laryngeal mask airway (LMA). Note the swivel "T" connector attached to the neck of the LMA.

 

   Discussion
Top
 Abstract
 Introduction
 Discussion
References
 
Performing an awake, fiberoptic intubation for a recognized difficult airway in the pediatric population is challenging, if not impossible secondary to the lack of cooperation by the sedated child. Some alternatives to direct laryngoscopy include blind light wand technique, blind nasal intubation, and oral or nasal fiberoptic intubation; however, these techniques are often more difficult in the pediatric population. These difficulties might be avoided by first attempting intubation through an LMA rather than direct laryngoscopy. Intubating children with difficult airways fiberoptically through an LMA has gained much popularity because the LMA reliably provides a patent airway. This has been observed in children with both normal and difficult airways (3,4). In addition, advantages of fiberoptically intubating through the LMA include controlled ventilation of the anesthetized patient and the ability of the LMA to serve as a conduit for fiberoptic intubation.

Multiple techniques have been described for intubating through the LMA in children (5–10). If the LMA does not interfere with the surgical procedure, it can be left in place (11). However, the greatest challenge encountered when intubating through an LMA is how to remove the LMA without dislodging the ETT from the trachea. This difficulty is unique to the pediatric anesthesiologist. Because the lengths of an age-appropriate pediatric ETT and LMA are similar, the proximal end of the ETT tends to disappear into the LMA once the ETT has passed through the vocal cords. This makes it difficult to safely remove the LMA without dislodging the ETT (10–12). One can circumvent this problem by extending the length of the pediatric ETT. Commonly, the proximal end of one ETT is wedged into the distal end of a similar size ETT without using some type of fastening device (13–16). We secured the ends of two tubes by using a cut endotracheal connector as a female-to-female adapter (Fig. 1). We believe our method is superior to other methods, because it firmly holds the two ETTs together, is easy to assemble, adds additional stability to the ETT apparatus, and avoids the need to cut or modify the LMA (17,18). Our apparatus maintained a firm attachment between the ETTs and significantly reduced the chance of dislodging the distal part of the ETT from the larynx while removing the LMA.

In summary, we do not suggest abandoning direct laryngoscopy as a first look. However, we suggest pediatric anesthesiologists think about performing a rather atraumatic fiberoptic intubation through the LMA as his/her first intubation attempt in a child with a potentially difficult airway, using two ETTs secured via a cut ETT connector.


   References
Top
 Abstract
 Introduction
 Discussion
 References
 

  1. Posnick JC, Ruiz RL. Treacher Collins syndrome: current evaluation, treatment, and future directions. Cleft Palate Craniofac J 2000; 37: 434.[Web of Science][Medline]
  2. Jones KL. Smith’s recognizable patterns of human malformation. 5th ed. Philadelphia PA: WB Saunders, 1997.
  3. Rowbottom SJ, Simpson DL, Grubb D. The laryngeal mask in children: a fibreoptic assessment of positioning. Anaesthesia 1991; 46: 489–91.[Web of Science][Medline]
  4. Walker RW. The laryngeal mask airway in the difficult airway: an assessment of positioning and use in fibreoptic intubation. Paediatr Anaesth 2000; 10: 53–8.[Web of Science][Medline]
  5. Wheatley RS, Stainthorp SF. Intubation of a one-day-old baby with the Pierre-Robin syndrome via a laryngeal mask. Anaesthesia 1994; 49: 733.
  6. White AP, Billingham IM. Laryngeal mask guided intubation in paediatric anaesthesia. Paediatr Anaesth 1992; 2: 343–4.
  7. Bahk J, Han S, Kim S. Management of difficult airways with a laryngeal mask airway under propofol anaesthesia. Paediatr Anaesth 1999; 9: 163–6.[Web of Science][Medline]
  8. Inada T, Fujise K, Tachibana K, Shingu K. Orotracheal intubation through the laryngeal mask airway in paediatric patients with Treacher-Collins syndrome. Paediatr Anaesth 1995; 5: 129–32.[Web of Science][Medline]
  9. Heard CM, Caldicott LD, Fletcher JE, Selsby DS. Fiberoptic-guided endotracheal intubation via the laryngeal mask airway in pediatric patients: a report of a series of cases. Anesth Analg 1996; 82: 1287–9.[Web of Science][Medline]
  10. Silk JM, Hill HM, Calder I. Difficult intubation and the laryngeal mask. Eur J Anaesthesiol 1991; 4: 47–51.
  11. Ebata T, Nisiki S, Masuda A, Amaha K. Anesthesia for Treacher Collins syndrome using a laryngeal mask airway. Can J Anaesth 1991; 38: 1043–5.[Web of Science][Medline]
  12. Beveridge ME. Laryngeal mask anaesthesia for repair of cleft palate. Anaesthesia 1989; 44: 656–7.[Web of Science][Medline]
  13. Chadd GD, Walford AJ, Crane DL. The 3.5/4.5 modification for fiberscope-guided tracheal intubation using the laryngeal mask airway. Anesth Analg 1992; 75: 307–8.
  14. Reynolds PI, O’Kelly SW. Fiberoptic intubation and the laryngeal mask airway. Anesthesiology 1993; 79: 5.[Web of Science][Medline]
  15. Theroux MC, Kettrick RG, Khine HH. Laryngeal mask and fiberoptic endoscopy in an infant with Schwartz-Jampel syndrome. Anesthesiology 1994; 82: 605.
  16. Johnson CM, Sims C. Awake fibreoptic intubation via a laryngeal mask in an infant with Goldenhar’s syndrome. Anaesth Intensive Care 1994; 22: 194–7.[Web of Science][Medline]
  17. Hansen T, Joesen H, Henneberg SW, Hole P. Laryngeal mask airway guided tracheal intubation in a neonate with the Pierre-Robin syndrome. Acta Anaesthesiol Scand 1995; 39: 129–31.[Web of Science][Medline]
  18. Goldie AS, Hudson I. Fiberoptic tracheal intubation through a modified laryngeal mask. Paediatr Anaesth 1992; 2: 344.
Accepted for publication June 20, 2003.




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This Article
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press