Fibreoptic bronchoscopy in lateral position as a rescue airway management technique in a child with temporo-mandibular joint ankylosis.

Sir,

Tracheal intubation in the lateral position is sparsely practiced by anaesthesiologists because of inexperience and rare need. Flexible fibreoptic bronchoscopy (FOB) is the gold standard in the management of the anticipated difficult airway across all the age groups; however, its success depends on proper technique. Hereby, we report a case where lateral position facilitated ventilation as well as FOB-guided intubation.

A 13-year-old boy, who had unilateral congenital temporo-mandibular joint ankylosis with micrognathia and no mouth opening, was scheduled for mandibular distraction surgery. We had planned to perform FOB-guided nasotracheal intubation following inhalational induction while maintaining spontaneous ventilation. Under standard monitoring, anaesthesia was induced with incremental sevoflurane in 100% oxygen. With increasing anaesthetic depth, the child developed airway obstruction with chest indrawing and paradoxical abdominal movements, which did not get relieved with head tilt, and chin lift maneuver. So he was turned to the left lateral position with continued facemask anaesthesia, which immediately relieved the airway obstruction as evidenced by the absence of paradoxical breathing and presence of capnographic trace. A well-lubricated 6-mm ID nasopharyngeal airway (NPA) was inserted in the left nostril to continue oxygen and sevoflurane insufflations. Subsequently, FOB-guided intubation was performed successfully through the right nostril, in the same position. Intubation was attempted in lateral position in our case as there was no means of displacing the tongue away from the posterior pharyngeal wall. The jaw thrust and tongue pull were not possible to assist fibreoptic bronchoscopic visualisation of the larynx because of micrognathia and nil mouth opening.

A manikin-based study, assessing the ease of intubation among anaesthesia trainees, found intubation with direct laryngoscopy in the left lateral position to be more difficult, but the time to intubation improved on repeated attempts. This denotes the learning curve involved in intubation in lateral position.[1] The laryngoscopic view worsened in lateral position in 35% patients as compared with the supine position when direct laryngoscopy was performed by a senior anaesthesiologist.[2]

Although direct laryngoscopy may be difficult in the lateral position, FOB-assisted airway management was found to be easier. The FOB-guided intubation in the semilateral position was found to improve the glottic view as compared with the supine position without any assistance to displace the tongue.[3] In a similar study, the fibreoptic-guided intubation was found to have a higher first intubation success rate when performed in the lateral position.[4] The ease of performing FOB-guided intubation is attributed to the lateral displacement of tongue and secretions pooling in the dependent areas.

The FOB-guided intubation in lateral position is often preferred in situ ations where it will be difficult to place the patient in the supine position or supine position may result in significant risk of brain compression as in a case of absent occipital bone.[5] Although it is a known fact that lateral position improves the management of difficult airway, it is still considered as an unorthodox way of managing the airway amongst anaesthesiologists. Once the airway patency is achieved after the insertion of the NPA, it will be tempting to change the position to supine for subsequent intubation attempt. This may worsen the patency further or worsen the glottic view by tongue fall. In this case, we safely secured the airway using lateral positioning to our advantage. We suggest that the lateral position can be the position of choice for FOB-guided intubation, especially in a difficult airway scenario where the tongue cannot be displaced by other means.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient assent and parents' forms. In the form the patient's parent(s) has/have given his/her/their consent/assent for his/her/their child's images and other clinical information to be reported in the journal. They understand that the child's names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.