|Year : 2020 | Volume
| Issue : 3 | Page : 140-143
Failed fibreoptic bronchoscopy-guided intubation in a child with post-burn contracture and anticipated difficult airway: Videolaryngoscope to the rescue
Vibha Chhabra, Mukul Kumar Jain, Atul Sharma, Sudhir Singh
Department of Paediatric Anaesthesiology, Super Specialty Paediatric Hospital and Post Graduate Teaching Institute, New Delhi, India
|Date of Submission||30-Sep-2020|
|Date of Acceptance||07-Nov-2020|
|Date of Web Publication||25-Dec-2020|
Dr. Vibha Chhabra
Department of Paediatric Anaesthesiology, 2nd Floor, Super Specialty Paediatric Hospital and Post Graduate Teaching Institute, Sector-30, Noida, Gautam Budh Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
Airway management in a child with post-burn contracture (PBC) involving the face, anterior neck and chest is challenging for the anaesthesiologist. Although fibreoptic endoscopy-guided intubation is considered the gold standard for difficult paediatric airway, this may not always be useful. We report the successful management of a distorted airway in a 3-year-old girl scheduled for cosmetic correction of PBC under general anaesthesia. The initial attempt of fibreoptic endoscopy to secure the airway was unsuccessful. The child was subsequently managed by the release of contractures and videolaryngoscopy-guided intubation.
Keywords: Difficult paediatric airway, flexible fibreoptic bronchoscopy, post-burn contracture, videolaryngoscopy
|How to cite this article:|
Chhabra V, Jain MK, Sharma A, Singh S. Failed fibreoptic bronchoscopy-guided intubation in a child with post-burn contracture and anticipated difficult airway: Videolaryngoscope to the rescue. Airway 2020;3:140-3
|How to cite this URL:|
Chhabra V, Jain MK, Sharma A, Singh S. Failed fibreoptic bronchoscopy-guided intubation in a child with post-burn contracture and anticipated difficult airway: Videolaryngoscope to the rescue. Airway [serial online] 2020 [cited 2021 Apr 16];3:140-3. Available from: https://www.arwy.org/text.asp?2020/3/3/140/304850
| Introduction|| |
Perioperative management of post-burn sequelae involving the head and neck region in a paediatric patient poses a unique challenge to the attending anaesthesiologist and surgeon. Post-burn contractures (PBCs) or deformities involving the face, anterior neck and chest may result in restricted mouth opening, fibrosis of nose and external nares, decreased oropharyngeal space, fixed flexion deformity of neck, reduced compliance of submandibular space and limitation of extension at atlanto-occipital joint. Difficult airway management in a paediatric patient requires skill, competency and meticulous planning as any deviation can result in disastrous consequences. Mortality rate from difficult airway management in neonates and young children is estimated to be 30%–40% of all anaesthetic-related deaths.
Flexible fibreoptic bronchoscopy-guided (FFB-guided) intubation is considered the gold standard for the management of difficult paediatric airway. It is most widely used, but its application may have technical challenges, a steep learning curve and may not always be helpful, especially in significantly distorted airways. Videolaryngoscopy (VLS) can substantially improve glottic views without having to align the oral, pharyngeal and tracheal axes. However, this technique also has a limitation in children with restricted mouth opening.
Literature is scarce regarding the use of VLS in the setting of anticipated difficult airway following failure of FFB-guided intubation. We report the successful management of an anticipated difficult airway in a child with PBC of the face, neck, chest and upper limbs, resulting in distorted anatomy due to severe scars, contractures and fixed lateral flexion deformity of the neck.
| Case Report|| |
A 3-year-old girl weighing 10 kg, with an alleged history of accidental electrical burn 3 months earlier, was referred to our institute for reconstructive surgery of post-burn contractures. The parents disclosed a history of an unsuccessful attempt at 'placing a tube inside the windpipe' as mentioned to them by the anaesthesiologist from the referral centre. On examination, the patient had severe scar contractures involving the right side of the face, neck, axilla, anterior chest wall and right arm [Figure 1]. A contracture band was extending from both alae nasi involving the right angle of mouth, neck and trunk, resulting in a chin-chest position tilted towards the right side. Airway examination revealed limited mouth opening (< 1 cm), and restricted temporomandibular joint movements and neck extension. Both nostrils were not patent due to the presence of contracture bands. Modified Mallampati grading, thyromental distance and sternomental distance could not be evaluated. Her systemic examination, blood investigations and 12-lead electrocardiogram were unremarkable. The perioperative management plan, including tracheostomy, need for postoperative mechanical ventilation and possible stay in the intensive care unit were discussed with the parents and informed written high-risk consent was obtained. The management strategy was also thoroughly discussed with the consultant plastic surgeon, and meticulous planning and preparations were done for anticipated difficult intubation.
|Figure 1: Patient with post.burn contracture. Restricted mouth opening and fixed cervical lateral flexion deformity due to burn scar contracture involving the face, anterior neck and thorax|
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The child was kept nil per mouth for 6 h before surgery. An intravenous (IV) access was secured on the dorsum of the left hand with 20 SWG cannula in the ward after applying eutectic mixture of local anaesthetic cream. On arrival in the operation theatre, standard monitors were attached. All resuscitation equipment, including difficult airway cart, were kept ready. The fibreoptic bronchoscope (2.8 mm OD, Karl Storz-Endoscope, Germany) was checked, lubricated with water-soluble jelly and preloaded with a 4.0 mm ID cuffed endotracheal tube (ETT). The surgeon was prepared for emergency contracture release or tracheostomy if required. An IV infusion of Ringer Lactate was started, and IV glycopyrrolate 0.04 mg was given to reduce secretions. The airway was nebulised with 2 mL of 1% lignocaine with adrenaline for 10 min.
The child was preoxygenated for 5 min with 100% oxygen via face mask and paediatric circle system. After confirmation of bag mask ventilation, induction of anaesthesia was performed with sevoflurane in 100% oxygen. Ketamine 20 mg IV was administered over 5 min in small aliquots during induction while maintaining spontaneous ventilation. An assistant stabilised the child's head in a neutral position and held the mouth open. Oral fibreoptic bronchoscopy (FOB) was attempted, but vocal cords could not be visualised. A senior anaesthesiologist made a second unsuccessful attempt. Following the second failed attempt of FOB, mask ventilation was continued. Surgical release of contracture bands to facilitate mouth opening and orotracheal intubation was performed under tumescent local anaesthesia (TLA) using 50 mL of 0.1% lignocaine in adrenaline (1:200,000) solution infiltrated subcutaneously.
Following the release of the contracture band from the right angle of the mouth and neck, VLS was performed with C-MAC® Macintosh blade size-2 (Karl Storz SE and Co. KG, Tuttlingen, Germany), and a 10 Fr, 70 cm gum-elastic bougie was inserted under vision. An assistant retracted the right angle of mouth to create adequate space to insert a size 4.0 mm ID cuffed ETT over the bougie. The proper placement of the ETT was also confirmed with capnography and bilateral air entry on manual ventilation. Anaesthesia was maintained with oxygen in air (50:50), titrated MAC of sevoflurane and intermittent boluses of 0.1 mg/kg atracurium. The surgery lasted for 4 hours. Contractures on neck and right axilla were released, and skin grafts were placed. Intraoperatively, the child received Intravenous paracetamol 150 mg and fentanyl 20 μg for analgesia. IV ondansetron 1 mg, hydrocortisone 20 mg and dexamethasone 1.5 mg were also administered. Haemodynamic parameters were monitored throughout surgery, and her intraoperative course was uneventful.
After completion of the surgery the inhalation agent was discontinued, and she was kept on 100% oxygen. The residual neuromuscular blockade was reversed with IV 0.5 mg neostigmine and 0.1 mg glycopyrrolate. Once the child regained consciousness and fulfilled the criteria for extubation, the ETT was removed after gentle suctioning and deflation of the cuff. The child was shifted to the postanaesthesia care unit with an oxygen mask and observed for 2 hours. Her postoperative course in the hospital was uneventful and she was discharged after 5 days.
| Discussion|| |
The paediatric airway is different from that of an adult. Various factors such as a large head, short neck, anterior larynx, large tongue, small oral aperture and floppy epiglottis make management of even the normal paediatric airway challenging. In addition, PBC involving the head-and-neck region increases the complexity of airway management. The airway of a burn patient progressively becomes more difficult with time as the neck contracture worsens. In our patient, the obliterated nostrils due to fibrosis, restricted mouth opening, fixed lateral flexion of the neck towards the right side and inability to align the intubation axis due to the presence of contracture bands made the airway evaluation and management more difficult.
A preplanned airway management strategy in paediatric patients with PBC for reconstructive surgery is essential. In our patient, the nasal route for blind or FFB-guided nasotracheal intubation was unavailable due to narrowed nostrils. The use of supraglottic airway devices was also difficult due to restricted mouth opening and fixed flexion deformity. Hence, we decided to attempt orotracheal FFB-guided intubation. Although awake FFB is a safe and gold standard technique for difficult airway, this was not feasible in our patient as it requires patient's cooperation which was not expected from this young child. Hence, based on the previous history of an unsuccessful intubation attempt in our patient, we decided to use FFB after inhalation induction with sevoflurane with the maintenance of spontaneous ventilation. We used titrated doses of ketamine in addition to sevoflurane to provide analgesia and attenuate the stress response during FFB while still maintaining the spontaneous respiration.
In our case, oral FFB was difficult due to anatomic alteration as a result of PBC, and two attempts were unsuccessful. In such a situation, fibreoptic-compatible oral airway or anterior mobilisation of the tongue by manual traction is reported to be helpful to facilitate navigation of the fibrescope past the hypopharynx. Both were not possible in our case due to restricted mouth opening. Hence, we decided to go for surgical release of neck contractures under TLA. Low-dose TLA has been reported to be safe as sole loco-regional anaesthetic technique for surgical release of PBC neck in paediatric patients.,
C-MAC VLS is reported to be useful to facilitate tracheal intubation following failed FFB intubation in adult patients with PBC neck. It has been shown to improve the visual field and helps in tracheal tube exchange without losing visualisation in the cases of abnormal anatomy. The limitations for the use of VLS are restricted mouth opening and anterior displacement of the larynx due to PBC neck. It has been reported to be advantageous over various intubation techniques, including FFB in children with challenging airways in only one case report. Sinha et al. reported the successful use of C-MAC VLS in an 11-year-old child with a large parapharyngeal mass in whom a previous attempt with oral FFB, direct laryngoscopy and GlideScope® VLS failed to visualise the glottis and epiglottis. In our patient, the intubation was performed under C-MAC VLS over gum elastic bougie.
A surgical colleague with experience of performing tracheostomy in difficult airway should be readily available in the operation theatre before induction of such patients. Other techniques such as retrograde wire-guided intubation or percutaneous needle cricothyrotomy may be used as a last resort but can be difficult in children with PBC and associated distorted anatomy.
We conclude that thorough evaluation, meticulous planning and eternal vigilance are the keys to successful perioperative management in recovered paediatric burn patients with an anticipated difficult airway. VLS could be a useful aid for intubation following failed FFB.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given consent for images and other clinical information to be reported. The guardian understands that the name and initials 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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