Infant feeding tube stiffened with guide wire as endotracheal tube exchanger and introducer in difficult airways!

Sir,

Paediatric airway is difficult because of large occiput, narrow nares, large tongue, narrow epiglottis, high larynx and narrow cricoid region. It is equally difficult to exchange endotracheal tubes (ETT) in children. ETT exchangers are easy to use, but they are not very safe because of their stiffness.[1] Fiberoptic bronchoscopy (FOB) is one of the options to exchange ETT[2] but appropriate sizes are not readily available for children. The unexpected difficult pediatric airway can be handled by experienced anesthesiologists in a better way and the expected difficult airway requires dedicated anesthesia specialists, at specialized centers.[3] Here we report the use of infant feeding tube stiffened with guide wire as ETT exchanger in an infant.

A 10-month-old girl weighing 3 kg, known case of Pierre Robin syndrome with cleft palate, was scheduled for atrial septal defect (ASD) closure and tongue lip adhesion. We anticipated difficult airway because of micrognathia, macroglossia, receding mandible and cleft palate. Detailed informed consent for failed intubation and tracheostomy was taken. Injection glycopyrrolate was administered as premedication. Difficult airway cart including stylet, laryngeal mask airways (LMAs), oropharyngeal airway and FOB were kept ready. Paediatric bougie was not available in the hospital. After shifting child to the operating room (OR) routine monitors such as electrocardiogram and pulse oximetry were attached. Child was preoxygenated and anesthetized using midazolam 0.2 mg/kg, fentanyl 3 mcg/kg and sevoflurane. Mask ventilation was adequate and suxamethonium bolus was administered at 1 mg/kg. First direct laryngoscopy with a curved blade revealed Cormack-Lehane grade IV view and endotracheal (ET) intubation attempt failed. Second attempt with straight blade and stylet inside ETT also failed. LMA ventilation was out of our plan because of planned tongue lip adhesion procedure. Plan B was to attempt intubation with FOB. Till FOB was brought in OR, third attempt was made with direct laryngoscopy. Blind ET intubation was successful this time with size 3.0 portex ETT. There was a significant leak around ETT even with flexion of head and packing of oropharynx. This leak compelled us to exchange this 3.0 size ETT to 4.0 size tube. As appropriate bougie was unavailable, we inserted sterilized guide wire of 7.5 French gauze (FG) central venous catheter into infant feeding tube of size 7 FG after cutting its distal end. The guide-wire made nasogastric tube little stiffer as a ETT exchanger. This newly made tube exchanger was inserted into size 3.0 mm ETT under aseptic precautions [Figure 1]. This ETT was removed, and size 4.0 portex ETT was railroaded over this newly made bougie. ASD closure was done on cardiopulmonary bypass. At the end of ASD closure, tongue lip adhesion was released, and he was extubated successfully and discharged from hospital.

Figure 1

J tip guidewire and infant feeding tube with guidewire in situ

Literature addressing safe and effective airway exchangers are plentiful but many of the devices from various difficult airway protocols are still not readily available. Paediatric FOB may not be available in many setups and so could be the case with paediatric bougies or exchange catheters. There are various problems of ETT exchangers like trauma or tissue damage, mainly due to the associated stiffness.[4] There is one report where authors have used nasogastric tube as tracheal tube introducer.[5] However, smaller gauge nasogastric tube is very soft and pliable, thus may not have enough strength to use as an ETT introducer or exchanger. If we insert metallic, flexible guide wire into infant feeding tube it gives good strength, and this assembly may serve as a better ETT introducer or exchanger.