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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 163-165

Blind Tracheal intubation through Ambu AuraOnce™ in a child with Goldenhar syndrome for ophthalmic surgery

Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India

Date of Submission01-Oct-2020
Date of Acceptance20-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Vamsidhar Amburu
H. No. 302, 1/122, Old Rajinder Nagar, New Delhi - 110 060
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_43_20

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How to cite this article:
Amburu V, Soni SL, Gourav KP, Naik N. Blind Tracheal intubation through Ambu AuraOnce™ in a child with Goldenhar syndrome for ophthalmic surgery. Airway 2020;3:163-5

How to cite this URL:
Amburu V, Soni SL, Gourav KP, Naik N. Blind Tracheal intubation through Ambu AuraOnce™ in a child with Goldenhar syndrome for ophthalmic surgery. Airway [serial online] 2020 [cited 2023 Sep 21];3:163-5. Available from: https://www.arwy.org/text.asp?2020/3/3/163/304851

An 18-month-old boy weighing 10 kg, a known case of Goldenhar syndrome, was posted as a day-care procedure for excision of dermolipoma in the right eyelid. Examination revealed a hemifacial hypoplasia with a poorly developed mandible on the right? side, an external defect of the right nostril and a lipoma in the right eyelid [Figure 1]. A thorough preoperative evaluation was done by a paediatrician which revealed a small atrial septal defect. After confirmation of the fasting status, premedication with 4 mg of preservative-free midazolam was given orally in the preoperative holding area. After 25 min, the child was satisfactorily sedated and was shifted to the operating room. After discussion with the surgeon about the duration of surgery, a plan of placing a supraglottic airway device (SAD) was made.

Monitoring with noninvasive blood pressure, electrocardiograph, pulse oximeter and capnography was established. The child was induced with 8% sevoflurane in oxygen using a face mask. Following induction, intravenous access was established and 16 μg of fentanyl was given. After achieving adequate depth of anaesthesia, the supraglottic device (Ambu AuraOnce size #2) was? placed [Figure 2]. Anaesthesia was maintained using sevoflurane in oxygen and nitrous oxide. During surgery, manoeuvring the operating microscope became difficult due to the position of the SAD. It was decided that intubation would be necessary to continue with surgery in an unhindered manner. As the change of plan was not anticipated, the fibreoptic bronchoscope was not readily available. We decided to introduce the endotracheal tube (ETT) blindly through the SAD. After administration of 4 mg of atracurium, 100% oxygen was administered for 3 min and an uncuffed 4.0 mm ID ETT was passed [Figure 3]. There was a resistance in the midpath during intubation. The ETT was removed and the child was ventilated with 100% oxygen for a minute and a second attempt was made. This time, the ETT was lubricated with a water-soluble jelly on the external surface, facilitating smooth passage of the tracheal tube. The position of the ETT was confirmed with waveform capnography. Later, the ETT connector was removed and the Ambu AuraOnce was removed by push–pull technique while stabilising the ETT in the same? position using a stylet. The connector was reattached to the ETT and the circuit was connected. The chest was auscultated for confirming bilateral equal air entry and the tube was fixed. The rest of the intraoperative course was uneventful. At the end of surgery, residual neuromuscular blockade was antagonised with weight-adjusted dose of neostigmine and glycopyrrolate. Extubation was uneventful.
Figure 1: Child with Goldenhar syndrome

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Figure 2: Child with supraglottic airway in place

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Figure 3: Exchanging of Ambu AuraOnce with endotracheal tube in situ

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Goldenhar syndrome, first described by Maurice Goldenhar, is also known as oculoauriculovertebral dysplasia. It has several clinical manifestations such as craniofacial, vertebral, cardiac, renal and central nervous system anomalies.[1] It arises due to defective development of the 1st and 2nd branchial arches. The syndrome, in addition to its systemic ramifications, poses unique challenges during airway management. Features such as facial asymmetry, large head, micrognathia, cleft palate, hemifacial hypoplasia, malocclusion and vertebral anomalies contribute to difficult mask ventilation and intubation in these children. Given its complexity of airway anatomy, numerous devices have been successfully used to secure the airway in Goldenhar syndrome.[2],[3] Ambu AuraOnce is a single-use, disposable SAD used for achieving and maintaining airway control in both emergency and elective procedures. Its advantages include its unique design with a 70° curve that follows the airway anatomy. Most literature regarding intubation through Ambu AuraOnce recommend the use of an intubation fibrescope as the standard technique. The manufacturer recommends against blind tracheal intubation through this device. The success rates of blind tracheal intubation were reported between 3% and 76% in different studies, the variation mainly attributable to the technique of insertion and manoeuvring.[4],[5] Such a wide variation in the success rates of blind tracheal intubation through Ambu AuraOnce necessitates further evaluation and standardisation of the technique with ongoing research. A systematic meta-analysis comparing the efficacy and safety of Ambu AuraOnce with other SADs revealed it to be an effective alternative to Classic laryngeal mask airway (LMA), LMA Unique™ and Softseal™ in terms of ease of insertion and incidence of sore throat.[6]

In our case where the location of the operating room was remote and there was a need for quick switch to an ETT, acquiring a fibreoptic scope was rather difficult due to which we considered blind intubation through Ambu AuraOnce. Due to the acute curve of 70° between the bowl and shaft of the device, passing the ETT was expected to be difficult. We lubricated the external surface of the ETT with a water-soluble jelly to facilitate easy passage through the SAD. Prewarming of the ETT has also been recommended. As the technique is naive and still unexplored, there is a need for more studies to be done to address the difficulties in intubation through Ambu AuraOnce and describe techniques to overcome them.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Anderson PJ, David DJ. Spinal anomalies in Goldenhar syndrome. Cleft Palate Craniofac J 2005;42:477-80.  Back to cited text no. 1
Chen PP, Cheng CK, Abdullah V, Chu CP. Tracheal intubation using suspension laryngoscopy in an infant with Goldenhar's syndrome. Anaesth Intensive Care 2001;29:548-51.  Back to cited text no. 2
Haxby EJ, Liban JB. Fibreoptic intubation via a laryngeal mask in an infant with Goldenhar syndrome. Anaesth Intensive Care 1995;23:753.  Back to cited text no. 3
Anand L, Singh M, Kapoor D, Singh A. Comparative evaluation of Ambu Aura-i and Fastrach™ intubating laryngeal mask airway for tracheal intubation: A randomized, controlled trial. J Anaesthesiol Clin Pharmacol 2019;35:70-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
Kleine-Brueggeney M, Nicolet A, Nabecker S, Seiler S, Stucki F, Greif R, et al. Blind intubation of anaesthetised children with supraglottic airway devices Ambu Aura-I and Air-Q cannot be recommended: A randomised controlled trial. Eur J Anaesthesiol 2015;32:631-9.  Back to cited text no. 5
Baidya DK, Chandralekha C, Darlong V, Pandey R, Maitra S, Khanna P. Comparative efficacy and safety of the Ambu®AuraOnce™ laryngeal mask airway during general anaesthesia in adults: A systematic review and meta-analysis. Anaesthesia 2014;69:1023-32.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]

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