Tuhin Mistry1, Neelam Dogra2, Priyanka Jain2, Kanchan Chauhan2. 1. Department of Anaesthesiology and Critical Care, S.M.S. Medical College, Jaipur, Rajasthan, India. 2. Department of Paediatric Anaesthesiology, Sir Padmapat Mother and Child Health Institute, S.M.S. Medical College, Jaipur, Rajasthan, India.
Sir,A 2-day-old male baby weighing 3 kg was referred to our institute for correction of bilateral choanal atresia. His birth history was unremarkable. When his mother had attempted to breastfeed him, the baby developed cyanosis and respiratory distress that was relieved on crying. On examination, resistance was encountered on insertion of infant feeding tube in each nostril. Computed tomography of the nose and paranasal sinuses were suggestive of bony choanal atresia (right > left) [Figure 1]. Clinical examination of other systems was within normal limits. Ultrasonography of whole abdomen revealed cystic dysplasia of left kidney.
Figure 1
Computed tomography scan of nose and paranasal sinuses showing bilateral choanal atresia
Computed tomography scan of nose and paranasal sinuses showing bilateral choanal atresiaThe baby was scheduled for endoscopic repair under general anesthesia. In the operating theater, standard monitors were attached. The baseline vitals noted were heart rate 140 beats/min, blood pressure 70/40 mm of Hg, SpO2 97% on room air, and the baby was crying excessively. He was premedicated with Glycopyrrolate 4 μg/kg intravenously (IV), fentanyl 1.5 μg/kg IV, and induced with sevoflurane in 100% O2. Muscle relaxation was achieved using succinylcholine 1.5 mg/kg. Laryngoscopy was done with Miller's blade size 0 (Cormack–Lehane grade 2) and his trachea was intubated with a 3.0 mm ID Microcuff Pediatric endotracheal tube (ETT) (Microcuff® Pediatric ETT, Kimberly Clark, Health Care, Atlanta, GA, USA) [Figure 2]. Bilateral air entry was confirmed, and the tube was fixed at 9 cm mark. The cuff was inflated with 1 ml of air with the goal of keeping the cuff pressure <10 cm H2O. Anesthesia was maintained with 50:50 mixture of oxygen and air, sevoflurane and IV atracurium. Paracetamol suppository 25 mg/kg was inserted and IV dexamethasone 0.1 mg/kg was given slowly. Intraoperatively, vitals and cuff pressure were monitored. At the end of surgery, neuromuscular block was reversed with IV glycopyrrolate 0.005 µg/kg and neostigmine 0.08 mg/kg and the baby was kept in the postanesthesia care room with supplemental oxygen through T-piece. Later, he was shifted to neonatal intensive care unit and his trachea was extubated 4 h after surgery. There were no postextubation complications such as hoarseness or stridor; respiratory rate was 30 breaths/min and there was no respiratory distress. Oral feeding was started from the next day. The patient was discharged on the 4th postoperative day with stents in situ.
Figure 2
Microcuff Pediatric endotracheal tube (size 3.0 mm ID)
Microcuff Pediatric endotracheal tube (size 3.0 mm ID)Bilateral choanal atresia is relatively rare than unilateral malformation and is deemed as lethal because neonates are obligatory nasal breathers.[1] The absence of respiratory distress at rest in our patient may be because of the presence of less deformity on the left side. Bilateral choanal atresia is commonly associated with syndromes such as CHARGE, Treacher–Collins, Kallmann, Pfeiffer, and VATER association.[1] Our patient was not associated with any of these syndromes.Transnasal endoscopic repair with placement of stents is the preferred method for management of bilateral choanal atresia in our institute. Common concerns during nasopharyngeal surgery in neonates with traditional uncuffed ETT include accidental tube dislocation, ineffective ventilation due to excessive air leak because of inadequate seal, aspiration of blood and secretions in spite of packing, laryngeal and tracheal damage due to inappropriate size of the tube, and imprecise measurement of end-tidal CO2 concentration.[2]We planned to use Microcuff® Pediatric ETT in our patient to prevent aspiration of blood and secretion associated with airway surgery during intraoperative and postoperative period. Moreover, the standard cuffed ETT are not available for neonates, and they do not conform to pediatric airway anatomy and has high cuff pressure. Microcuff® Pediatric ETT has ultrathin polyurethane cuff membrane (10 μ) which ensures a true high volume low-pressure seal and the low cuff pressure (<10 cm H2O) reduces the risk of airway trauma and mucosal injury. Also, intubation depth marks and short, cylindrical cuff near tip allow adequate placement with a cuff free subglottic zone without the risk of endobronchial intubation.[3] Dullenkopf et al. evaluated Microcuff® Pediatric ETT in 500 children (range: Newborn to 13 years) and observed a very low rate of tube exchange (1.6%) as well as airway morbidity (croup requiring therapy, 0.4%).[4]The cuff of this tube is highly permeable to nitrous oxide that can increase the cuff pressure. Dullenkopf et al. observed that though N2O exposure increases cuff pressure similar to conventional ETT cuffs, improved sealing characteristics of Microcuff® Pediatric ETT allows a longer time interval until unsafe cuff pressure is reached in children.[5] Hence, continuous cuff pressure monitoring and repeated readjustments are recommended when N2O is used in children. We used air in oxygen to avoid increase in cuff pressure and also monitored cuff pressure until the tracheal extubation.To conclude, Microcuff® Pediatric ETT may be used safely in neonate during transnasal endoscopic correction of bilateral choanal atresia without chances of aspiration, airway morbidity, and improved postoperative outcome.
Figure 1
Figure 2