Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome

Abstract

The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.

Flexible bronchoscopic intubation through the AuraGain™ laryngeal mask versus a slit Guedel tube: a non-inferiority randomized-controlled trial

“…5,6 Flexible bronchoscopic intubation through a slit Guedel tube remains one of the most common practices in expected difficult intubation, yet bronchoscopic intubation via a supraglottic airway may now be considered an alternative approach. 2,[7][8][9][10] This is an easier alternative for the management of the difficult airway, as it offers younger less experienced anesthesia providers an easier handling method to gain sufficient and safe practice in bronchoscopic awake intubation. 11 Orotracheal bronchoscopic intubation may be facilitated by diverse airway or supraglottic devices, such as the slit Guedel tube or the Ovassapian airway (Hudson RCIÒ), which help guide the flexible bronchoscope to the glottic opening.…”

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video‐Assisted Laryngoscopy

“…5,9 Furthermore, it has been documented as being utilized in combination with fiberoptic bronchoscopy as a primary step in endotracheal intubation in patients with difficult visualization. 13,14 Chen and Hsiao demonstrated 90.5% correct position placement by paramedic students in a normal airway during a simulated pediatric resuscitation scenario. 5 A study by Guyette et al demonstrated a 100% LMA insertion rate in testing paramedic students in a similar normal scenario.…”

“…It is a defined treatment in difficult and craniofacial pediatric airways and, once learned, becomes an expeditious way to secure an advanced airway without the need for direct visualization 5,9 . Furthermore, it has been documented as being utilized in combination with fiberoptic bronchoscopy as a primary step in endotracheal intubation in patients with difficult visualization 13,14 . Chen and Hsiao demonstrated 90.5% correct position placement by paramedic students in a normal airway during a simulated pediatric resuscitation scenario 5 .…”

The design of the perfect pediatric supraglottic airway device

“…Although the Laryngeal Mask Airway Classic and Unique have been used successfully as conduits for fiberoptic intubation in children, their airway tube design makes them less than ideal. Having a long, narrow airway tube creates many obstacles, especially when trying to remove the SGA when a cuffed tracheal tube is used.…”