: 2019  |  Volume : 2  |  Issue : 2  |  Page : 89--92

Airway management following assessment by virtual bronchoscopy subsequent to failed intubation in a child with tetralogy of Fallot

Mayuri Golhar1, Tarun Yadav1, Mangal Singh Ahalawat1, Prashant Kumar1, Samsher Singh Lochab2,  
1 Department of Anaesthesiology, Pt BDS PGIMS, Rohtak, Haryana, India
2 Department of Cardiac Surgery, Pt BDS PGIMS, Rohtak, Haryana, India

Correspondence Address:
Dr. Tarun Yadav
Department of Anaesthesiology, Pt BDS PGIMS, Rohtak, House No 187, Sector 2, Rohtak - 124 001, Haryana


Children with congenital anomaly have a higher incidence of a difficult airway. Routine airway assessments have their limitations due to low sensitivity for predicting airway difficulties. We report the successful airway management of a 10-year-old girl with tetralogy of Fallot who had a history of failed intubation. Virtual bronchoscopy revealed subglottic narrowing. Careful planning on the basis of virtual bronchoscopy findings leads to a successful perioperative course. We recommend that virtual bronchoscopy be used as an airway assessment tool in anticipated difficult airway.

How to cite this article:
Golhar M, Yadav T, Ahalawat MS, Kumar P, Lochab SS. Airway management following assessment by virtual bronchoscopy subsequent to failed intubation in a child with tetralogy of Fallot.Airway 2019;2:89-92

How to cite this URL:
Golhar M, Yadav T, Ahalawat MS, Kumar P, Lochab SS. Airway management following assessment by virtual bronchoscopy subsequent to failed intubation in a child with tetralogy of Fallot. Airway [serial online] 2019 [cited 2020 Feb 25 ];2:89-92
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Full Text


The paediatric airway is considered to be different to that of adults due to anatomical and physiological variations. In the presence of a co-existent congenital cardiac anomaly such as tetralogy of Fallot (TOF), the incidence of tracheal defects is higher.[1] Current airway assessment tools have poor ability to predict outcome. Besides, assessment of the subglottic region is rarely done.[2] Virtual bronchoscopy is a novel computed tomography (CT) based imaging technique that allows a noninvasive intraluminal evaluation of the tracheobronchial tree.[3] We describe a case of a young girl with a history of failed intubation who was managed successfully by careful planning with the help of findings based on virtual bronchoscopy.

 Case Report

A 10-year-old girl with TOF was to undergo total correction of TOF under general anaesthesia. Routine preoperative airway evaluation was unremarkable. After induction of general anaesthesia, laryngoscopy was performed using appropriate-sized Macintosh blade and good glottic view was obtained. A 4.5-mm ID endotracheal tube (ETT) could not be negotiated beyond the glottis after initial unsuccessful attempts using ETT sizes 6.0 mm ID and 5.0 mm ID. A paediatric fibreoptic bronchoscope was not available.

As bag and mask ventilation was possible, the child was awakened to avoid possible trauma due to unplanned airway manipulation. Surgery was deferred for further assessment and evaluation. It was jointly decided by the anaesthesiologist, cardiothoracic surgeon, and ENT surgeon that a more complete radiological airway assessment needed to be performed. Virtual bronchoscopy with reconstruction from CT scan revealed subglottic tracheal narrowing (length of about 1 cm with the narrowest anteroposterior diameter of approximately 5 mm) and diffuse oedematous changes of bilateral vocal cords [Figure 1] and [Figure 2]. The patient was rescheduled for surgery 2 weeks later. As we already knew the diameter of the narrowest subglottic segment (approximately 5 mm by virtual bronchoscopy), we attempted to pass a 4.0 mm ID ETT which was successfully negotiated past the narrowest subglottic segment.{Figure 1}{Figure 2}

The 4.0 mm ID ETT was replaced with a 5.0 mm ID ETT without any difficulty. Unlike a previous attempt with a 5.0 mm ID ETT, it was possible this time to negotiate the tube as the airway oedema had resolved. Correct placement of ETT was confirmed with five point auscultation and square wave capnographic trace. Trachestomy was available as a rescue measure. The 4.0 mm ID ETT was replaced with a 5.0 mm ID ETT. The rest of the intraoperative period remained uneventful. At the end of surgery, percutaneous tracheostomy was done with 6.0 mm ID tracheostomy tube to avoid any airway compromise in the postoperative period.


Preoperative anatomical knowledge of the airway and the tracheobronchial tree is an important factor in the successful management of patients with predicted difficult airway. Assessment of the subglottic region is rarely done. The subglottic region can be assessed noninvasively using recent technology which generates virtual images with the help of a software that integrates data derived from multirow detector X-ray CT scans.[4]

TOF is associated with an 11% incidence of tracheal anomaly.[1] Careful preoperative airway assessment of the tracheobronchial tree should be done to preempt any unforeseen airway emergency. Virtual bronchoscopy can serve as a noninvasive tool to make airway evaluation more complete. However, it has the limitation of availability and the hazard of exposure to radiation.

Despite these limitations, virtual bronchoscopy is a good tool for airway assessment in a selected group of patients. At present, there is lack of extensive evidence in literature to support this investigative modality. Based on our experience of this case, we believe that research in the use of virtual bronchoscopy for preoperative airway assessment through well-designed clinical trials will confirm its efficacy in patients with predicted difficult airway.


Virtual bronchoscopy is a noninvasive investigation that can be used for visualisation and anatomic evaluation of the airway. We believe that it makes airway assessment more complete, thereby allowing planning of an appropriate airway management strategy to deal with predicted airway difficulty.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents of the patient have given their consent for her images and other clinical information to be reported in the journal. The parents understand that the name and initials of the patient will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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