Adjusting the endotracheal tube tip in management of tracheomalacia in an infant

Therapeutic flexible airway endoscopy of small children in a tertiary referral center-11 years' experience

OBJECTIVES

Use of therapeutic flexible airway endoscopy (TFAE) is very limited in pediatrics. We report our clinical experiences and long term outcomes of TFAE in small children from a single tertiary referral center.

METHODS

This is a retrospective cohort study. Small children with their body weight no more than 5.0 kg who had received TFAE between 2005 and 2015 were enrolled. Demographic information and outcomes were reviewed and analyzed from medical charts and TFAE videos.

RESULTS

A total of 313 TFAE were performed in 225 children. The mean age was 3.50 ± 0.24 (0.01-19.2) months old; the mean body weight was 3.52 ± 0.65 (0.57-5.0) kg. A noninvasive ventilation technique, without mask or artificial airway, was applied to support all the procedures. TFAE included laser therapy (39.6%), balloon dilatation plasty (25.6%), tracheal intubation (24.3%) and metallic stent placement (6.4%). Short-length endoscopes of 30-35 cm were used in 96%. All TFAE were successfully completed without serious adverse events or mortality. Mean procedural time was 27.6 ± 16.1 minutes. TFAE resulted in successful extubation immediately in 67.2% (45/67) and 62.8% (118/188) were able to wean off their positive pressure ventilation support in 7 days after procedures. By the end of this study, these TFAE averted the originally suggested airway surgeries in 93.8% (61/65), as benefited from laser therapy, stent implantation, and balloon dilatation plasty.

CONCLUSIONS

The TFAE modality of using short-length endoscopes as supported with this noninvasive ventilation and ICU support is a viable, instant and effective management in small children. It has resulted in rapid weaning of respiratory supports and averted more invasive rigid endoscopy or airway surgeries.

Flexible bronchoscopy as a valuable diagnostic and therapeutic tool in pediatric intensive care patients: a report on 5 years of experience

OBJECTIVE

To evaluate the clinical role of flexible bronchoscopy (FB) in pediatric and neonatal intensive care units (ICUs).

DESIGN

A retrospective review of all patients receiving FB procedures between January 2005 and December 2009.

SETTING

Pediatric and neonatal ICUs of a tertiary care multi-disciplinary teaching hospital located in northern Taiwan.

PATIENTS

A total of 358 ICU patients (223 males) who received 725 FB procedures.

MEASUREMENTS AND MAIN RESULTS

The medical records were reviewed and analyzed. Mean age for the first time FB was 35.7 (±48.9 SD) months old and 68.2% of them were <3 years old. Among them, unexplained retraction or tachypnea (32.0%) and stridor (20.1%) were the two leading indications for FB. The positive finding rate of FB was 87.2%, with airway malacia (47.8%) being the most common, especially in patients <3 years old. Positive lesion sites were approximately equally distributed between the upper (51.1%) and lower (50.6%) airways. Concomitant findings in the esophagus were found in 15.4% of the patients. There were 518 interventional FBs (71.4%, 518/725 procedures) which were performed on 201 (56.1%, 201/358) patients; FB-aided endotracheal intubation (180/518, 34.7%) and laser therapy (109/518, 21.0%) were the two leading techniques used. No patient suffered from any long-term complications or mortality associated with the FB procedures.

CONCLUSIONS

FB is a safe and valuable diagnostic and therapeutic tool for patients in pediatric and neonatal ICUs.

Airway management in an infant with double aortic arch

A 2-month old male was admitted due to repeated cyanotic attacks. He had suffered from stridor and retractive breathing since birth. Double aortic arch was diagnosed and the vascular ring formed by the double aortic arch was compressing the trachea. Multirow detector computed tomography showed that he had a right-dominant double aortic arch with left ductus arteriosus and an aberrant left subclavian artery, and that the narrowest part of the trachea, where the diameter was 2.0 mm, was located 9.0 mm above the carina. Airway management in patients with extreme narrowing of the trachea is challenging for anesthesiologists. He was scheduled for ligation and division of the left aortic arch and ductus arteriosus. In the operating theater, anesthesia was slowly induced with sevoflurane (0-4%) in oxygen. After mask ventilation was confirmed to be adequate, a 4.0 mm internal diameter endotracheal tube (ETT) was inserted and advanced smoothly beyond the tracheal stenosis. The tip of the ETT was placed just above the carina using a fiber optic bronchoscope (fiberscope) that was passed through the ETT. Since mechanical ventilation was adequate, vecuronium was administered. Surgery was conducted in the right lateral position and using a left thoracotomy approach. Anesthesia was maintained with sevoflurane (2-3%). After positioning, right one-lung ventilation was performed unexpectedly. However, anesthetic management was achieved without difficult ventilation during surgery. The tip of the ETT was pulled past the stenotic part before transfer to the intensive care unit (ICU). A patent trachea during spontaneous breathing under CPAP (5 and 2 cmH(2)O) was confirmed with a bronchofiberscope in the ICU. After weaning from mechanical ventilation, he had the persistence of mild stridor despite improvement of respiratory symptoms.