Converting a nasoendotracheal tube to orotracheal, following fibreoptic intubation under general anaesthesia in a paediatric patient with complete cleft palate.

Abstract

Sir, Cleft lip and palate are commonly associated with retrognathia, micrognathia and glossoptosis,[1] and can be part of syndromes such as Pierre Robin syndrome, Treacher-Collin's syndrome or Goldenhar syndrome. The anaesthesiologists frequently face difficulty with airway maintenance, mask ventilation, laryngoscopy, and endotracheal intubation.[2] Many of these infants may require fibreoptic intubation when they come for surgery.[3] We are reporting a case of Pierre Robin syndrome posted for palatoplasty. The patient, 9-month-old male infant, was delivered normally and had a history of snoring and nasal regurgitation while feeding. On examination, mandible was markedly receding along with a complete cleft palate involving both soft and hard palates. After keeping the child nil per oral for 6 h, general anaesthesia was induced with 8% sevoflurane in oxygen using a Jackson Rees circuit. Following induction a nasopharyngeal airway was introduced through one nostril with an endotracheal tube connector attached to the proximal end. Anaesthesia was maintained with 4% sevoflurane in oxygen with Jackson Rees circuit connected to the airway. Electrocardiogram, non-invasive blood pressure, SpO2 and end-tidal CO2 (EtCO2) were monitored. A 4.0 mm internal diameter oral Ring-Adair-Elwyn (RAE) tube was loaded on to the paediatric bronchoscope and the child was intubated nasally through the opposite nostril. As the surgeons insisted on an oral tube, the nasal tube was pushed in till the proximal end was at the nostril [Figure 1]. Then the mouth was opened and the most proximal part of the endotracheal tube visible through the cleft was caught with a paediatric Magill's forceps and pulled into the oral cavity [Figure 2]. At the same time, the part of the tube in the pharynx was stabilised by pushing it posteriorly to the pharyngeal wall with the index finger of the left hand to prevent accidental extubation. Once the proximal end of tube was brought out through the oral cavity, endotracheal tube connector was attached and position confirmed with EtCO2 and auscultation. The tube was then fixed in the midline and surgery commenced after giving fentanyl 2 μg/kg and atracurium 0.5 mg/kg intravenously. Maintenance of anaesthesia was with O2 :N2O (1:2) with sevoflurane (1.5–2%). The child was extubated at end of surgery uneventfully after reversing the neuromuscular blockade and when fully awake.Figure 1: Nasal endotracheal tube being pushed in till the proximal end is at the nostrilFigure 2: Proximal end of endotracheal tube being pulled out through the oral cavityThough infants can be intubated orally with fibreoptic bronchoscope, technical ease is more with the nasal route. Fibreoptic intubation succeeds less frequently by oral route because of the greater angle between oral cavity and the laryngeal inlet and also since keeping the bronchoscope in the midline is more difficult with oral route.[4] Though a nasotracheal tube can be changed to orotracheal using a guide wire, in the presence of a complete cleft palate, the technique described by us can be safely and easily accomplished.