Managing the challenging pediatric airway: Continuing Professional Development

Airway Management for Massive Anterior Mediastinal Tumor Resection in an Infant: A Strategy Involving Spontaneous Breathing-Preserving Endotracheal Intubation under Intravenous Anesthesia

Tracheal intubation under sedation in uncooperative infants is challenging. The case of a 4-month-old infant with a massive anterior mediastinal tumor and upper respiratory tract symptoms, for whom effective preoxygenation was provided with a high-flow nasal cannula (HFNC), allowing for safe tracheal intubation in combination with a supraglottic device and local anesthetic, is reported. With careful planning of anesthesia and creative problem solving, airway management for anterior mediastinal tumors can be performed safely with the selection of an appropriate airway device. This may be a good airway management strategy for infants with mediastinal tumors or who may be expected to have ventilation difficulties.

Case report: The art of anesthesiology-Approaching a minor procedure in a child with MPI-CDG

Background: Protein glycosylation plays an important role in post-translational modification, which defines a broad spectrum of protein functions. Accordingly, infants with a congenital disorder of glycosylation (CDG) can have N-glycosylation, O-glycosylation, or combined N- and O-glycosylation defects, resulting in similar but different multisystem involvement. CDGs can present notable gastrointestinal and neurologic symptoms. Both protein-losing enteropathy and hypotonia affect the decision of using anesthetics. We reported a case of MPI-CDG with protein-losing enteropathy and muscular hypotonia that underwent different anesthesia approach strategies of vascular access. Here, we highlight why intubation with sevoflurane anesthesia and sparing use of muscle relaxants is the optimal strategy for such a condition. Case presentation: A 25-month-old girl, weighing 6.6 kg and 64 cm tall, suffered chronic diarrhea, hypoalbuminemia, and hypotonia since birth. Protein-losing enteropathy due to MPI-CDG was documented by whole-exome sequencing. She underwent three sedated surgical procedures in our hospital. The sedation was administered twice by pediatricians with oral chloral hydrate, intravenous midazolam, and ketamine, to which the patient showed moderate to late recovery from sedation and irritability the following night. The most recent one was administered by an anesthesiologist, where endotracheal intubation was performed with sevoflurane as the main anesthetic. The patient regained consciousness immediately after the operation. She had no complications after all three sedation/anesthesia interventions and was discharged 7 days later, uneventful after the third general anesthesia procedure. Conclusion: We performed safe anesthetic management in a 25-month-old girl with MPI-CDG using sevoflurane under controlled ventilation. She awoke immediately after the procedure. Due to the disease entity, we suggested bypassing the intravenous route to avoid excess volume for drug administration and that muscle relaxant may not be necessary for endotracheal intubation and patient immobilization when performing procedures under general anesthesia in CDG patients.

The Effects of a Shoulder Roll During Laryngoscopy in Infants: A Randomized, Single-Blinded, Crossover Study

BACKGROUND

The use of a shoulder roll to view the glottic opening during direct laryngoscopy in infants has been recommended but is not evidence based.

METHODS

Twenty infants with normal airways, <6 months of age undergoing elective surgery under general anesthesia were randomized to undergo direct laryngoscopy first with a 2-inch vertical shoulder roll and then without, or vice versa. The primary outcome was the difference in the vertical distance between the angle of the laryngoscopist's eye and the operating room table in the 2 positions. Also, the views of the glottic opening in both positions were recorded for each infant and analyzed by a blinded investigator using the percent of glottic opening (POGO).

RESULTS

Twenty infants completed the study without complications. The vertical distance did not differ significantly whether the shoulder roll was placed first or second, and there was no evidence of a differential carryover effect in the crossover design (P = .268). The main effect of the shoulder roll on the mean (95% confidence interval [CI]) vertical distances without 47.8 cm (43.5-52.1) and with the shoulder roll 37.2 cm (33.3-41) yielded a mean (95% CI) vertical difference of 10.6 cm (9.3-11.79; P = .0001). The median (interquartile range [IQR]) POGO scores without 100 [86.2, 100] and with the shoulder roll 97.5 [80, 100] did not differ (median difference [95% CI]: 0 [-20 to 0]; P = .39).

CONCLUSIONS

A 2-inch shoulder roll lowers the line of sight of the glottic opening compared with no shoulder roll, without affecting the view of the glottic opening during laryngoscopy in infants.

Concurrent Use of Videolaryngoscope and Fiberoptic Bronchoscope in a Child with Neurofibromatosis to Facilitate Endotracheal Intubation

INTRODUCTION

In children who have craniofacial asymmetry secondary to neurofibromatosis type 1, the securing of the airway can be challenging. These patients have varying degrees of head and neck tumors that complicate endotracheal intubation. Anesthesiologists have many techniques and devices that assist us in securing adult airways and these devices are available in pediatric sizes which can also be used to safely secure the smaller airways.

CASE

This 13-year-old male patient with Neurofibromatosis presented with a 2 cm mouth opening, Mallampati IV assessment, and thyromental distance of 2 cm for surgery. During the previous management of this child's airway it was found to be difficult using the fiberoptic bronchoscope or the Glidescope alone.

DISCUSSION

This is a case report of improvement of intubating conditions using both devices concurrently.

Improvement of laryngoscopic view by hand-assisted elevation and caudad traction of the shoulder during tracheal intubation in pediatric patients

Pediatric patients have large heads and relatively small bodies, making it difficult to perform intubation even in the sniffing position. Therefore, this study was planned on the assumption that hand-assisted elevation and caudad traction of the shoulder (HA-ECTS) would compensate for the laryngoscopic view. In this observational study, 45 pediatric patients aged 0–36 months with an ASA physical status of I-III and scheduled for elective surgery under general anesthesia were enrolled. HA-ECTS was defined as hand-assisted personalized traction in the upper and caudad directions with both hands under the lower cervical area. The POGO (percentage of glottis opening) score, MO (mouth opening), and LHS (laryngoscopic handling score) were compared before and after HA-ECTS. The median [range] POGO score was 30[10–50]% and 60[15–80]% before and after HA-ECTS, respectively (median difference, 20; 95% confidence interval [CI] 10 to 25%; P = 0.002). MO was 1.0[0.8–1.9] cm and 1.8[1.3–2.0] cm before and after HA-ECTS, respectively (median difference, 0.45 cm; 95% CI 0.25 to 0.60; P < 0.001). The ease of laryngoscopic handling was improved after HA-ECTS(P < 0.001). The application of HA-ECTS to pediatric patients younger than 3 years improved POGO score, MO, and LHS and could prove to be an assistive technique for tracheal intubation.

A comparison between McGrath MAC videolaryngoscopy and Macintosh laryngoscopy in children

BACKGROUND

This prospective, randomised, controlled study was performed to evaluate the usefulness of the McGrath VL compared with Macintosh laryngoscopy in children with expected normal airway during endotracheal intubation, by comparing the time to intubation and difficulty of intubation.

METHODS

Eighty-four patients aged 1-10 years who underwent endotracheal intubation for elective surgery were randomly assigned to the McGrath group (n = 42) or the Macintosh group (n = 42). Anaesthesia was induced with 2.5-3.0 mg/kg of propofol and sevoflurane 5-8 vol%. Orotracheal intubation was performed 2 min after injection of rocuronium 0.6 mg/kg with McGrath VL or Macintosh laryngoscope; the primary outcome was the time to intubation. The Cormack and Lehane glottic grade, intubation difficulty score (IDS), and success rate on intubation were assessed. Haemodynamic changes were also recorded.

RESULTS

As the primary outcome, median time to intubation [interquartile range] did not differ between the McGrath group and the Macintosh group (25.0 [22.8-28.3] s vs. 26.0 [24.0-29.0] s, P = 0.301). The incidence of grade I glottic view was significantly higher in the McGrath group than in the Macintosh group (95% vs. 74%, P = 0.013). Median IDS was lower in the McGrath group than in the Macintosh group (0 [0-0] vs. 0 [0-1], P = 0.018). There were no significant differences in success rate on intubation or haemodynamics between the two groups.

CONCLUSIONS

McGrath VL provides better laryngeal views and lower IDS but similar intubation times and success rates compared with the Macintosh laryngoscope in children with normal airway.

Effectiveness of tip rotation in fibreoptic bronchoscopy under different experimental conditions: an in vitro crossover study

Background

Proper manipulation of fibreoptic bronchoscopes is essential for successful tracheal intubation or diagnostic bronchoscopy. Failure of proper navigation and rotation of the fibrescope may lead to difficulties in advancing the fibrescope and might also be responsible for (unnecessary) difficulties and delays in fibreoptic tracheal intubation, with subsequent hypoxaemia. The present study, therefore, aimed to assess the effectiveness of tip rotation in flexible bronchoscopes in different experimental conditions.

Methods

Five differently sized pairs of fibrescopes (outer diameters of 2.2, 2.4, 3.5, 4.2, and 5.2 mm) were inserted into paediatric airway manikins via an appropriately sized laryngeal mask and were turned clockwise or anticlockwise at the fibrescope body or cord to 45, 90, and 180°, with the cord held either straight or bent. The primary outcome measure was the ratio of rotation measured at the tip over the rotation performed with the fibrescope body or cord.

Results

Overall, the 'body' turn was significantly less effective when a bent cord was present (mean difference ranging from 29.8% (95% confidence interval 8.8-50.9) to 117.4% (93.6-141.2). This difference was diminished when the 'cord' turn was performed. Smaller fibrescopes, with outer diameters of 2.2 and 2.4 mm, were inferior with respect to the transmission of 'body' rotation to the tip.

Conclusions

'Cord' turning of the fibrescope appears to be more effective in rotating the tip than a turn of the fibrescope 'body' only. Straightening the fibrescope cord and combined 'body' and 'cord' turning are recommended.