Trachlight-guided intubation in small infant with difficult airway.

To the Editor,

Difficult airway in an infant is a challenging task for every anesthesiologist. Flexible fiberoptic bronchoscope (FFB) is often considered as the first choice but is not readily available in the small size required for infants. In recent years, pediatric light wand has proved to be a suitable alternative to FFB for difficult and failed pediatric airway.[123] We report the management of an infant with known difficult airway using a trachlight (TL) guided orotracheal intubation.

A 3-month-old infant weighing 4.2 kg presented to us with a rapidly growing neuroectodermal tumor of the anterior maxilla and was scheduled for excision. The tumor was table tennis ball-sized and protruding over whole of the mouth opening, more toward the right side [Figure 1]. Airway examination revealed mouth opening of around 2 cm with a normal neck extension. On the morning of surgery, after securing an intravenous access, the infant was premedicated with 0.02 mg/kg atropine intravenously. Induction of anesthesia was done with sevoflurane in oxygen. After check ventilation with an appropriately sized oral facemask, direct left paraglossal straight blade laryngoscopy was performed and a Cormack-Lehane Grade III view was obtained, but because of the swelling there was little space to intubate under direct vision. Pediatric bougie was introduced but failed to pass through vocal cords even after two attempts. Partial airway obstruction occurred which was relieved by insertion of a nasopharyngeal airway and the ventilation was resumed. Midline direct laryngoscopy was avoided as there were chances of tumor manipulation and bleeding. Thereafter, an infant TL TM (Lederal Medical Corporation, New York, USA) (TL) was loaded with size four endotracheal tube (ETT) and bent to an angle of 90°. This assembly was introduced into the airway after applying anterocaudad jaw thrust. A bright glow was seen in the anterior neck and was repositioned until a well-defined glow was seen in midline below the laryngeal prominence which indicated the tip of TL at glottic opening and was advanced gently into the trachea. Emission estimation technique was rail-loaded over it successfully and was confirmed by EtCO2 and bilateral chest auscultation. This whole process of TL-guided intubation was completed in <30 s without any complications such as desaturation, apnea or laryngeal spasm. Thereafter, fentanyl 2 μg/kg and atracurium 0.5 mg/kg were given. The surgical procedure, extubation, and postoperative period were uneventful.

Figure 1

3-month-old infant with neuroectodermal tumor of the anterior maxilla more toward the right side

Flexible fiberoptic intubation is advocated as the choice for management of the difficult airway[4] but has got several limitations as FFB of such smaller size is not available in every institute. Moreover, pediatric FFB is thinner and pliable and is not suitable for railroading ETT as it may sometimes get stuck on epiglottis, arytenoids or corniculate cartilages.[5]

The use of the light wand for managing the difficult airway in both adults and children has been described in the literature.[1236]

Xue et al.[1] reported four pediatric cases aged 6-10 years with craniofacial abnormalities who were managed with TL-guided intubations when posted for ear reconstruction. Fisher and Tunkel[2] showed successful use of TL in 125 children under the age of 10 years with normal airway. Ours is the first reported case of use of TL in such a small infant with an anticipated difficult airway. Isolated case reports[78] have advised its cautious use in infants because of the greater transillumination of neck. This case report highlights the fact that light wand guided intubation is one alternative even in infants with difficult airway where FFB is not available in small sizes or failed fiberoptic intubation as this technique is also less likely to be affected by blood and secretions.