Letters to the Editor
Fiberoptic Bronchoscopic
Guidance for Intubating a Child with Pierre-Robin
‘1‘0 the Editor: We have read with interest the recent case report by Scheller attd Schuhnan and have used a similar technique to tacilitate endotracheal intubation in a child with Pierre-Kobin syndrome. A 2%month-old, 10 kg mate child with this ct-aniofacial def’ormity, characterized by severe tnicrognathia, glossoptosis, and a midline clef’t palate def’ot-mity of’ the hard and sof’t palales, presented for repair of’ the clef’t. When Lhe patienc was 26 months of’ age, clefi palate repair was postponed due to the inability to intubate the trachea via direct laryngoscopy with the patienL spontaneously breathing under halothane anesthesia. Thus, a fïberoptic orotracheal intubation using a guide wire in a spontaneously breathing anesthetized patient was plannecl. The child received 10 &kg of’ atropine intramuscularly (IM) 90 minutes prior IO arri\,al in the preopcrative holding area, al which time, 4 tttgikg of 1%’ lidocaine was administered via a nebulizet(Baxter Healthcare (:orp.. \‘alencia, (3) connected to a highconcentration oxygen (Oy) mask (Hospitak Incorporatetl, Lindenhurst, NY). In the operative thearer, a mask induction was accomplished with 70r intubation. i\f’ter placement of’ at1 intraIWWLIS (IV) catheter and with the child spontaneously 100% O,, the fïberoptic bt-onchoscope (~tymbt-eathing PUS LF-1, Olympus (Iorp., ‘l‘okyo,Japan) was placed into the trachea via the oral cavity. Insertion was facilitated with a laryngoscope equipped with a # 1 Macintosh blade to lift che tongue f’rotn the posterior pharynx. A 0.0% inch-diameter, 14.i cm guide wire ((:ook (Zritical Care. Bloomington. IN) MXS passed via the suction port of’the bronchoscope into the trachea urtder direct visualiLation to ensure proper pfacement and to prevetit injury. The bronchoscope was removed (net- the guide &e, a 4.0 mm internal diameter. oral KAE endotracheal tube was passed into the trachea over the guide wire, and the guide wire was removed. Bilateral breath sounds were auscultated, carbon dioxide was detected by capnography,. and the endotracheal tube w:ts secured. advantages 1 his technique provides several distinct fi)r endotracheal intubation in rhe pediatrie patient with a diffïcult upper airwa).. By proceeditrg directlv to fïberopric bronchoscopic guidance, the trauma assoc~ated with multiple attempts at direct laryngoscopy, blind nasal in-
258
.J. Clin. Anesth.,
vol. 4, MayiJune
1992
Syndrome
tubation, andior retrograde blind intubation using a guide wire are avoided. hence improving visualization of pharyngeal structures. Gerttle use of’ a curved laryngoscope blade to lift anatomie structures from the field of viem f’acilitates visualization of the larynx. Administration of aerosolized lidocaine is an effective, simple method of providing topical anesthesia from the nasal and pharyngeal mucosa distally to the terminal bronchioles.It is easily accomplished in pediatrie patients sitting on a parettt’s lap and is more effective 3 an antisialagogue is admittistered approximately 1 hour previously.” If multiple or prolonged attempts at endotracheal intubation are required, nebulized local anesthetics may help To ensure suf‘fïcient anesthesia as the patient lightens from breathing room air. We agree with Scheller and Schulmanl that it is nat necessary to pass a cardiac catheter over the guide wire, as described by Stiles,’ since the endotracheal tube passes easily into the trachea over the guide ivire. Appropriate preoperative evaluation and preparation 01’the patient with a diffïcult upper airway (i.~., I’ierreKobin syndrome) is paramount for successful endotracheal intubation and patient welfare. The technique deset-ibed bas been a useful addition to our armamentariuttt fol- management of the diffïcult pediatrie airway.
Robert J. Suriani, MD Resident Department of Anesthesiolog) Richard Assistant
D. Kayne, Professor
MD of‘ Anesthesiotogy
and
Pediatrics
Mount Sinai School of Medicine New York, NE’ 1002!~
References Scheller ,JC;. Schuhnan SR: Pit>er-optic bronchoscopic guidance lor intubating a neonate with Pierre-Robin syndrome. / C/r,, Anf&~ 1991:3:43-5. Bourke DL, Katz j, ‘l‘onneson X: Nebulized anesthesia for awakc endotracheal intubation. Awsthesiolog 1985;63:690. Barash PG, (:ulien RF, Smelting RK: Clinicnl Anathazu. Philadelphia: J.B. Lippincott, 19X9:552. Stiles CM: A flexible fïberoptic bronchoscope for endotracheal intubation of infanrs. .4n& A-\valg1974;53:1017-9.
Fiberoptic Bronchoscopic
Guidance for Intubating a Child with Pierre-Robin
‘1‘0 the Editor: We have read with interest the recent case report by Scheller attd Schuhnan and have used a similar technique to tacilitate endotracheal intubation in a child with Pierre-Kobin syndrome. A 2%month-old, 10 kg mate child with this ct-aniofacial def’ormity, characterized by severe tnicrognathia, glossoptosis, and a midline clef’t palate def’ot-mity of’ the hard and sof’t palales, presented for repair of’ the clef’t. When Lhe patienc was 26 months of’ age, clefi palate repair was postponed due to the inability to intubate the trachea via direct laryngoscopy with the patienL spontaneously breathing under halothane anesthesia. Thus, a fïberoptic orotracheal intubation using a guide wire in a spontaneously breathing anesthetized patient was plannecl. The child received 10 &kg of’ atropine intramuscularly (IM) 90 minutes prior IO arri\,al in the preopcrative holding area, al which time, 4 tttgikg of 1%’ lidocaine was administered via a nebulizet(Baxter Healthcare (:orp.. \‘alencia, (3) connected to a highconcentration oxygen (Oy) mask (Hospitak Incorporatetl, Lindenhurst, NY). In the operative thearer, a mask induction was accomplished with 70r intubation. i\f’ter placement of’ at1 intraIWWLIS (IV) catheter and with the child spontaneously 100% O,, the fïberoptic bt-onchoscope (~tymbt-eathing PUS LF-1, Olympus (Iorp., ‘l‘okyo,Japan) was placed into the trachea via the oral cavity. Insertion was facilitated with a laryngoscope equipped with a # 1 Macintosh blade to lift che tongue f’rotn the posterior pharynx. A 0.0% inch-diameter, 14.i cm guide wire ((:ook (Zritical Care. Bloomington. IN) MXS passed via the suction port of’the bronchoscope into the trachea urtder direct visualiLation to ensure proper pfacement and to prevetit injury. The bronchoscope was removed (net- the guide &e, a 4.0 mm internal diameter. oral KAE endotracheal tube was passed into the trachea over the guide wire, and the guide wire was removed. Bilateral breath sounds were auscultated, carbon dioxide was detected by capnography,. and the endotracheal tube w:ts secured. advantages 1 his technique provides several distinct fi)r endotracheal intubation in rhe pediatrie patient with a diffïcult upper airwa).. By proceeditrg directlv to fïberopric bronchoscopic guidance, the trauma assoc~ated with multiple attempts at direct laryngoscopy, blind nasal in-
258
.J. Clin. Anesth.,
vol. 4, MayiJune
1992
Syndrome
tubation, andior retrograde blind intubation using a guide wire are avoided. hence improving visualization of pharyngeal structures. Gerttle use of’ a curved laryngoscope blade to lift anatomie structures from the field of viem f’acilitates visualization of the larynx. Administration of aerosolized lidocaine is an effective, simple method of providing topical anesthesia from the nasal and pharyngeal mucosa distally to the terminal bronchioles.It is easily accomplished in pediatrie patients sitting on a parettt’s lap and is more effective 3 an antisialagogue is admittistered approximately 1 hour previously.” If multiple or prolonged attempts at endotracheal intubation are required, nebulized local anesthetics may help To ensure suf‘fïcient anesthesia as the patient lightens from breathing room air. We agree with Scheller and Schulmanl that it is nat necessary to pass a cardiac catheter over the guide wire, as described by Stiles,’ since the endotracheal tube passes easily into the trachea over the guide ivire. Appropriate preoperative evaluation and preparation 01’the patient with a diffïcult upper airway (i.~., I’ierreKobin syndrome) is paramount for successful endotracheal intubation and patient welfare. The technique deset-ibed bas been a useful addition to our armamentariuttt fol- management of the diffïcult pediatrie airway.
Robert J. Suriani, MD Resident Department of Anesthesiolog) Richard Assistant
D. Kayne, Professor
MD of‘ Anesthesiotogy
and
Pediatrics
Mount Sinai School of Medicine New York, NE’ 1002!~
References Scheller ,JC;. Schuhnan SR: Pit>er-optic bronchoscopic guidance lor intubating a neonate with Pierre-Robin syndrome. / C/r,, Anf&~ 1991:3:43-5. Bourke DL, Katz j, ‘l‘onneson X: Nebulized anesthesia for awakc endotracheal intubation. Awsthesiolog 1985;63:690. Barash PG, (:ulien RF, Smelting RK: Clinicnl Anathazu. Philadelphia: J.B. Lippincott, 19X9:552. Stiles CM: A flexible fïberoptic bronchoscope for endotracheal intubation of infanrs. .4n& A-\valg1974;53:1017-9.
