Innovative management of difficult paediatric airway, using antegrade seldinger technique.

Sir,

We report the airway management in a 4-year-old patient presenting for reconstruction surgery of the face. [Figure 1] Patient had developed complete loss of mouth opening following necrotising infection of the face. Facial reconstruction using a deltopectoral flap was planned under general anaesthesia. Premedication drugs included intravenous glycopyrrolate 0.1mg kg-1; midazolam 100mcg kg-1; 4% atomised lignocaine; intranasal xylometazoline drops, 15 minutes before induction of anaesthesia. Induction of anaesthesia was done with intravenous ketamine 1mg kg-1; fentanyl 2mcgkg-1(in small aliquots); sevoflurane in gradual increments. Spontaneous ventilation and bag-mask ventilation were ensured. After induction, 2ml of 4% lignocaine was injected intratracheally to facilitate fiberoptic bronchoscope (FOB) assisted intubation.

Figure 1

Image of the patient, showing extensive disfigurement of the face with irregular dentition and poor mouth opening

A 5mm endotracheal tube (ETT) was considered appropriate for tracheal intubation; lack of mouth opening mandated nasotracheal intubation, using a FOB. A 5mm FOB was available with us, but it did not allow loading of a 5mm ETT over it; a smaller FOB was not available. To overcome this major deficit, we improvised the plan of tracheal intubation.

The improvised plan was to perform laryngoscopy with FOB inserted through the left nostril; the injection port of FOB was used to spray 4% lignocaine over glottis. Once vocal cords had ceased to move, FOB was inserted through the glottis. An assistant entered the J-end of a long guidewire (guidewire used in cardiac angiography) through the biopsy channel of the FOB (Karl Storz, Germany fibreless flexible bronchoscope) till guidewire was visible at the distal end of the FOB. With the appropriate movements of the FOB, the distal end of the guidewire was guided into one of the bronchi (to ensure that adequate length of guidewire was inside the airway, to prevent dislodgement when FOB would be withdrawn). FOB was withdrawn gradually, leaving the guidewire in the trachea. Once FOB was completely withdrawn, it was reinserted to visualize the glottis and ensure that the guidewire had not got dislodged. A 4.5-mm ETT was rail loaded over the guidewire, rotation of ETT had to be done to negotiate the anterior commissure. ETT was secured insitu after ensuring bilateral air entry; surgery could proceed uneventfully; trachea was extubated after completion of the operation. This way, we avoided tracheostomy in a paediatric patient which seemed imminent in the absence of paediatric FOB.

The railroading of ETT over a guidewire passed per trachea is also done in retrograde intubation (RI). We did not consider RI in this case due to two reasons; first, RI is a blind procedure, predisposing the airway to trauma and bleeding.[1] Second, lack of mouth opening would have made railroading impossible if the guidewire had come out through the mouth instead of the nostril (as it happens in a majority of the cases).

Guidewire-assisted intubation is well tolerated even in an awake patient and does not impose any obstruction to airway or breathing. Conventional guidewires are prone to kinking which may cause complications and failure to intubate.[2] To overcome this problem, modification of ETT with the incorporation of a separate channel for guidewire is in the development phase but are not commercially available. Guidewire passed through a laryngeal mask airway has been used for intubation.[3] Although similar technique has been described in adult patients but this case can be a useful addition to the literature because, firstly, to the best of the author's knowledge, this is the first case of tracheal intubation using antegrade seldinger technique in a paediatric patient.[4] Contrary to adults, children have smaller airways which may result in higher chances of guidewire dislodgement when FOB is being removed, resulting in failed intubation. In order to prevent this we introduced an extra step of performing check laryngoscopy just to ensure that guidewire had not got dislodged. Secondly, this technique may be used at centers which have limited resources, as was the case with us (paediatric FOB was unavailable).

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.