Use of two tracheal tubes and fibreoptic bronchoscope for intubation through a LMA Pro‐Seal® in a difficult paediatric airway

Abstract

In a case of predicted difficult intubation in a 5-year-old child, we induced anaesthesia with sevoflurane in oxygen. We were able to establish adequate mask ventilation with help of a size 2 oropharyngeal airway (Intersurgical Ltd., Berkshire, UK). After deepening the plane of anaesthesia, we inserted a size 2 laryngeal mask airway (LMA Pro-Seal®; LMA North America, Inc. San Diego, CA, USA). We then introduced a 2.2-mm flexible fibreoptic bronchoscope (Karl Storz GMBH & Co, Tuttlin, Germany) through the LMA to evaluate its position and the tracheal lumen, and to negotiate the tracheal tube under direct vision. A 4-mm external diameter tracheal tube is the maximum recommended size that can be inserted through a size 2 LMA Pro-Seal. However, the length of this tube is such that it just crosses the bowl of the LMA Pro-Seal. We therefore attached a 3.5-mm external diameter uncuffed tracheal tube to the connector end of a 4-mm tube (Flexicare medical Ltd., Mid Glamorgan, UK) as a tube stabiliser and extension. Following introduction of the assembly through the LMA, we were able to advance both tubes off the fibrescope and site the 4-mm tracheal tube just above the carina. We removed the bronchoscope and then the LMA over the two tubes. We disconnected the 3.5-mm tube and attached a standard connector to the 4-mm tracheal tube. We were able to maintain spontaneous ventilation until the trachea was successfully intubated, and we would recommend this technique to aid intubation in the difficult paediatric airway.