Neonatal Airway Management Research Articles

Computer-assisted midface reconstruction in Treacher Collins syndrome part 1: Skeletal reconstruction

IntroductionTreacher Collins syndrome (TCS) is a severe and complex craniofacial malformation affecting the facial skeleton and soft tissues. The palate as well as the external and middle ear are also affected, but his prognosis is mainly related to neonatal airway management. Methods of zygomatico-orbital reconstruction are numerous and currently use primarily autologous bone, lyophilized cartilage, alloplastic implants, or even free flaps. This work developed a reliable “customized” method of zygomatico-orbital bony reconstruction using a generic reference model tailored to each patient. MethodsFrom a standard computed tomography (CT) acquisition, we studied qualitatively and quantitatively the skeleton of four individuals with TCS whose age was between 6 and 20 years. In parallel, we studied 40 controls at the same age to obtain a morphometric database of reference. Surgical simulation was carried out using validated software used in craniofacial surgery. ResultsThe zygomatic hypoplasia was very important quantitatively and morphologically in all TCS individuals. Orbital involvement was mainly morphological, with volumes comparable to the controls of the same age. The control database was used to create three-dimensional computer models to be used in the manufacture of cutting guides for autologous cranial bone grafts or alloplastic implants perfectly adapted to each patient's morphology. Presurgical simulation was also used to fabricate custom positioning guides permitting a simple and reliable surgical procedure. ConclusionsThe use of a virtual database allowed us to design a reliable and reproducible skeletal reconstruction method for this rare and complex syndrome. The use of presurgical simulation tools seem essential in this type of craniofacial malformation to increase the reliability of these uncommon and complex surgical procedures, and to ensure stable results over time.

Complications of Rigid Laryngoscopy and Tracheal Intubation

To the Editor: We read with great interest the article of Lee JJ et al. that describes two complications of tracheal intubation in a neonate.1We believe, however, that these two complications could have been avoided if the following precautions and techniques were used. (1) Tracheal intubation was achieved after three esophageal intubations. It was not mentioned if the esophageal intubation was done because of difficult airway or involved an endoscopist not experienced in neonatal intubation. If the case was difficult airway and the glottis was not seen, a supraglottic airway such as an Air-Q™#1.0 (Clearwater, FL) could have been immediately inserted to provide ventilation. If an endotracheal intubation is mandatory, a fiberoptic-guided tracheal intubation through the Air-Q™ can be performed.2(2) Proper placement of the endotracheal tube (ETT) to 8 cm distance at the lips could have avoided the right endobronchial intubation if the ETT was pulled to 8 cm at the lips and not left at 11 cm while starting positive pressure ventilation. (3) Proper placement of the ETT can be confirmed by: bilateral breath sounds, capnogrpahy, and insertion of a lubricated ultra-thin fiberoptic scope through the ETT (Olympus LF-P [Center Valley, PA] with a 2.2 mm external diameter) and confirming placement of the ETT (1.0–1.5 cm) above the carina in this case. If these precautions were followed, the endobronchial intubation and unnecessary surgery for gastric perforation from esophageal intubation could have been avoided. The authors have currently concluded that specialized training and experience are needed for neonatal airway management. However, use of a supraglottic airway as described above improves the likelihood of successful airway management by less experienced clinicians.

Airway management in neonates and infants with congenital airway lesions

Airway management in neonates and infants with congenital airway lesions

Two Complications of Tracheal Intubation in a Neonate

AN infant delivered in a private hospital after 33 weeks' gestation weighed 2,050 g, had persistent tachypnea, and had associated hypoxia requiring intubation. After three esophageal intubations, the neonate's trachea was successfully intubated. Despite mechanical ventilation, the infant had persistent tachycardia, hypoxemia (80–90% oxygen saturation) and a distended abdomen. A preoperative radiograph of this child shows the endotracheal tube tip in the right main bronchus (arrow A ), atelectasis of the entire left lung (arrow B ), pneumoperitoneum (white arrows ), and increased abdominal gas. At surgery, a 1.5-cm perforation of the anterior wall of the lesser curvature of the stomach was identified and repaired.The radiograph emphasizes critical complications that can occur during airway management of a neonate. Inadvertent esophageal intubation is one of the most common causes of neonatal intubation failure, which can lead to catastrophic consequences.1This condition can be rapidly detected by using end-tidal carbon dioxide monitoring, because it is the single most useful method in confirming endotracheal tube position.2In this neonate, gastric perforation likely occurred as a result of distension associated with positive pressure ventilation after esophageal intubation. Endobronchial intubation is another common problem associated with airway management in a neonate. This child's atelectasis likely developed after main stem intubation, when the endotracheal tube depth was noted to be 11 cm. As a guide to proper tracheal placement of an endotracheal tube, 1-, 2-, or 3-kg babies are intubated to a depth of 7, 8, or 9 cm, respectively.3These two complications reinforce the need for specialized training and experience in neonatal airway management.

The Supreme Laryngeal Mask Airway™ (LMA): A new neonatal supraglottic device: Comparison with Classic and ProSeal LMA in a manikin

AimThe study aims to compare the performances (ease of insertion, time to establish effective ventilation and maximal inflation pressure) of classic™ (cLMA), ProSeal™ (PLMA) and Supreme™ (SLMA) Laryngeal Mask Airway when used in a neonatal airway management manikin by inexperienced delivery room trainees. The quality of the three devices, as perceived by participants, was also evaluated. MethodsHealth-care professional trainees were given a brief supervised training with the three devices. Every trainee was then observed positioning each of the three different LMAs in a single occasion. Success rate, time (IT) and maximal inflation pressure (PImax) were recorded by a single unblinded observer. A 4-point scale was used to rate participants’ perceived quality. ResultsA total of 40 health-care professional trainees participated in the study.There were five, three and one failed insertions at the first attempt with the cLMA, PLMA and SLMA, respectively. No failures to establish an effective airway within three attempts were recorded. The success rate at first attempt was comparable among the three devices. The mean IT was significantly lower with the SLMA as compared with PLMA (p<0.01), but not to cLMA. The mean PImax was higher with SLMA than with cLMA and PLMA (p<0.01). The ease of insertion as well as the effectiveness of ventilation were perceived by the participants as superior with SLMA as compared with cLMA and PLMA (p<0.01). ConclusionsNeonatal SLMA is superior to PLMA in terms of time to establish effective ventilation; furthermore, maximal inflation pressure and quality perceived by the operator are higher with neonatal SLMA than with cLMA and PLMA. These manikin data could provide a useful guide for planning potential future clinical research involving the newly developed supraglottic device in neonates.

Oral Synechia with Epithelial Cyst in Neonate with Cleft Palate: A Case Report

Cleft palate with oral synechia is a rare congenital deformity that is represented in the literature by only a handful of cases. Midline synechia is less common than lateral. Failure to recognize and appropriately treat this condition has serious implications for neonatal airway management and feeding. We present a case of cleft palate with midline subglossopalatal synechia that was transferred from an outside institution after a prolonged period of nonsurgical management in which the patient ultimately required intubation for respiratory distress. Release of the synechia was performed without complications. We review the current literature and discuss diagnosis and surgical management of this rare condition.

Airway exchange catheters use in the airway management of neonates and infants undergoing surgical treatment of laryngeal stenosis

Congenital and acquired upper airway obstruction in infants commonly manifests as an acute, potentially life-threatening condition or a slow and gradual deterioration and can be a challenge to the pediatric anesthesiologist. This case series reports the nonconventional use of pediatric airway exchange catheters emergent and short-term airway management and lung ventilation in neonates and infants with severe laryngotracheal stenosis. After the approval of local Institutional Review Board, 11 consecutive patients presenting with severe laryngotracheal stenosis exceeding 70% were prospectively studied. Median (range) age and weight were 32 days (0-96) and 2.7 kg (2.1-3.4), respectively. Induction of anesthesia consisted of sevoflurane 5% in oxygen followed by sevoflurane 3% in an air/oxygen mixture (Fio2 = 0.5). Spontaneous ventilation was maintained in all patients. The trachea was intubated using an Airway Exchange Catheter with an inner diameter of 1.6 mm (Cook Airway Exchange Catheters, Cook Medical, Bloomington, IN). An Airway Exchange Catheter was inserted through the stenosis and manually assisted ventilation was confirmed using capnography. Median (range) ventilation duration was 28 minutes (12-61 mins). In one neonate, the Airway Exchange Catheter failed to ensure proper ventilation and an emergency tracheostomy was performed. Respiratory distress was likely due to a significant increase in airway resistance at the stenosis level or distal accumulation of secretions. Airway exchange catheters represent a useful additional tool for short-term advanced airway management for both oxygenation and ventilation in neonates and infants presenting with severe laryngotracheal stenosis.

Mandibular Distraction Osteogenesis to Relieve Pierre Robin Severe Airway Obstruction in Neonates

Airway management in neonates with Pierre Robin sequence is often challenging. Advancement of the tongue base using mandibular distraction in neonates can avoid tracheotomy and is increasingly propagated. The surgical indication is very important. We establish indication. The result of the preoperative peripheral oxygen saturation of about 40% in the prone position is considered as indication. The distance from postpharyngeal wall to lingual root of more than 5 mm is considered as contraindication; however, distance of less than 2 mm is considered needing performing mandibular distraction in preoperative lateral cephalometric radiograph. A three-dimensional computed tomographic demonstrating severity of retrognathia was generated preoperatively in the computed tomography room. The osteotomies can be performed by extraoral approaches. Nowadays, for precise bone cutting, Surgybone (Silfradent Co., Sofia, Italy) devices have been introduced in maxillofacial surgery, which we used for extraoral-approach osteotomies in 6 patients presented in this study. Distraction was performed after bilateral oblique osteotomy and removed after 1-month fixation in the second stage. A follow-up examination after removal of the distractors was performed. Normal appearance and no apnea were observed at 6 months' follow-up.

Laryngeal tube suction II for difficult airway management in neonates and small infants

Objective Difficult paediatric airways, both expected and unexpected, present major challenges to every anaesthesiologist, paediatrician and emergency physician. However, the integration of supraglottic airway devices, such as the laryngeal mask (LM), into the algorithm of difficult airways has improved the handling of difficult airway situations in patients. A recent device for establishing a supraglottic airway is the laryngeal tube, introduced in 1999. We report on the successful use of the laryngeal tube suction II (LTS II) in securing the airway when endotracheal intubation or alternative mask ventilation has failed. Methods The use of the LTS II in 10 cases of difficult airway management in neonates and infants <6 months was reviewed. Results Use of the LTS II was associated with a high level of success (100%), often rescuing the airway when other techniques had failed. All insertions were successful on first attempt using a modified insertion technique. Placement was classified as “easy” by all users. Conclusions The potential advantage of the LTS II is the suction port which allows gastric tube placement and subsequent egression of gastric contents. In emergency situations when direct laryngoscopy fails, or is too time-consuming because of anatomical abnormalities, we recommend the LTS II tube as the first-line device to secure the airway. As with all supraglottic airways, familiarity and clinical experience with the respective device and its insertion technique is essential for safe and successful use, especially in emergencies.

Airway Management in Neonates with Occipital Encephalocele: Easy Does It

To the Editor: Management of the airway of neonates presenting for surgical repair of a large occipital encephalocele may require more than one person to support the body and the head and to avoid pressure on the encephalocele sac.1,2 We present a simple alternative using readily available foam-cushion devices (Figs. 1 and 2). With this approach, the child can be positioned supine, only one person is needed to manage the airway, and pressure on the sac is easily avoided.Figure 1.: Platform build with blankets and foam-cushion.Figure 2.: Neonate with large encephalocele positioned supine allowing for easy airway management and protection of fragile encephalocele sac.Zenaide Quezado, MD Department of Anesthesiology and Pain Medicine Children’s National Medical Center George Washington University, Washington, DC Department of Anesthesia and Surgical Services NIH Clinical Center, National Institutes of Health Bethesda, Maryland [email protected] Julia C. Finkel, MD Department of Anesthesiology and Pain Medicine Children’s National Medical Center George Washington University, Washington, DC

Airway management in neonates with occipital encephalocele – adjustments and modifications

Pediatric AnesthesiaVolume 17, Issue 11 p. 1119-1120 Airway management in neonates with occipital encephalocele – adjustments and modifications Nilanjan Dey MD, Nilanjan Dey MD Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorKanti Kumar Gombar MD, Kanti Kumar Gombar MD Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorAshish Kumar Khanna MBBS, Ashish Kumar Khanna MBBS Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorPurva Khandelwal MBBS, Purva Khandelwal MBBS Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this author Nilanjan Dey MD, Nilanjan Dey MD Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorKanti Kumar Gombar MD, Kanti Kumar Gombar MD Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorAshish Kumar Khanna MBBS, Ashish Kumar Khanna MBBS Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this authorPurva Khandelwal MBBS, Purva Khandelwal MBBS Department of Anesthesiology and Intensive Care, Government Medical College and Hospital Chandigarh, India(email: nilanjandey@yahoo.com)Search for more papers by this author First published: 25 September 2007 https://doi.org/10.1111/j.1460-9592.2007.02311.xCitations: 10Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume17, Issue11November 2007Pages 1119-1120 RelatedInformation

Airway management and anesthesia in neonates, infants and children during endolaryngotracheal surgery

Endolaryngotracheal surgery in neonates, infants and children poses a big challenge for both anesthesiologist and surgeon. The narrowness of the airways and the great variability of the pathological lesions necessitate close collaboration between the surgical and the anesthesia team to provide optimal operating conditions and ensure adequate ventilation and oxygenation. Sixty-two anesthetic records of endolaryngotracheal surgical procedures in neonates, infants and children with ASA physical status 1-3 were analyzed retrospectively. Anesthesia was administered as total intravenous anesthesia; propofol supplemented with remifentanil. Ventilation was performed as supraglottic, superimposed high-frequency jet ventilation via jet laryngoscope with integrated jet nozzles. Age was 58.93 (SD 35.40) months, range 3 weeks to 14 years; body weight 17.83 (SD 8.79) kg, range 2.4-50 kg. The capillary pCO(2) 5 min after the start of the surgical procedure (n = 62) was 40.01 (SD 7.71) mmHg and after 20 min (n = 24) 41.77 (SD 7.12) mmHg. No hypoxemia (oxygen saturation <90%) developed. All patients were hemodynamically stable during jet ventilation. Barotrauma or gas insufflation in the stomach did not occur. No perioperative tracheostomy was necessary. Laryngospasm occurred in one child during emergence from anesthesia. Four infants received postoperative conventional respirator therapy in the ICU overnight. Supraglottic superimposed high-/low-frequency jet ventilation via jet laryngoscopes with integrated jet nozzles is a minimally invasive ventilation technique for neonates, infants and children in endolaryngotracheal surgery, which allows an unimpaired operating field for the surgeon especially in LASER surgery.

Tracheobronchial trauma associated with airway management in neonates.

Airway management procedures are an integral part of caring for the newborn infant with respiratory compromise. Concomitant with these interventions are latrogenic consequences that result in varying degrees of trauma to the tracheobronchial tree. Common interventions such as intubation, mechanical ventilation, use of heated and humidified gases, and endotracheal suctioning are discussed using research-based literature that evaluates the injury to the trachea and the mucociliary transport system.

Neonatal Resuscitation Using the Laryngeal Mask Airway

For a newborn requiring positive-pressure ventilation (PPV), the American Heart Association recommends bag-and-mask ventilation, a challenging procedure for those inexperienced in neonatal resuscitation. The objective of this prospective study was to evaluate the laryngeal mask airway (LMA) as an alternative method of airway management in neonates requiring PPV at birth. With the approval of the institutional ethics committee, consent was obtained from women in labor at a tertiary care-perinatal center. Inclusion criteria consisted of an expected birth weight of at least 2.5 kg, gestational age of at least 35 weeks, and resuscitation requiring PPV. Neonates meeting these criteria were resuscitated with PPV by means of the LMA. The ease of insertion, number of attempts required, time to establish effective ventilation, skin color, heart rate, respiratory effort, and Apgar scores were recorded. Attendance by the investigators at delivery was achieved in 93 cases, with 21 meeting the inclusion criteria. In all cases, the LMA was successfully inserted on the first attempt and provided a clinically patent airway. Twenty neonates were successfully resuscitated with the LMA to provide PPV, with no complications directly attributable to its use. One neonate required LMA removal and tracheal intubation to facilitate administration of epinephrine; data from this case was removed from the study. Providing PPV at birth via a size-1 LMA is effective and easily learned by personnel with expertise in neonatal resuscitation. The LMA should be further assessed as an alternative to bag-and-mask ventilation for this purpose.

Prolonged Intubation of Neonates

As the capabilities of modern medicine allow the survival of babies with increasingly lower gestational ages and birth weights, there is an increasing concern regarding the development of subglottic stenosis in those infants subjected to prolonged intubation. In this study, the general safety of neonatal intubation is assessed by a retrospective analysis of neonates who required intubation at Columbus (Ohio) Children's Hospital during a three-year period from 1977 to 1980. Of 343 surviving neonates, five (1.5%) developed clinically significant subglottic stenosis. The conclusion of this study is that endotracheal intubation is a safe method of airway management in neonates, even when used for extended periods.

Risk factors for neonatal acquired subglottic stenosis.

Endotracheal intubation has proven to be a relatively safe and effective means of securing the airway in neonates. Some concern remains, however, regarding airway management in critically ill infants who require assisted ventilation for extended periods. Among the various risk factors associated with the complication of acquired subglottic stenosis in neonates, the one most frequently cited has been "prolonged" intubation, although opinion varies regarding the definition of this term. Various recommendations exist that attempt to establish the limits of "safe" periods of intubation for infants. Some feel that tracheotomy is indicated when airway support is required beyond those limits. In an attempt to define important risk factors involved in the development of neonatal subglottic stenosis, a retrospective analysis of infants admitted to the Neonatal Intensive Care Unit of Columbus Children's Hospital who required intubation during a 3-year period from 1977 to 1980 was undertaken. Of 343 infants who survived hospitalization, five patients were identified as having acquired subglottic stenosis. The average duration of intubation for these five patients was 56.2 days. The incidence of subglottic stenosis for infants whose duration of intubation ranged from 3 to 50 days was 0.4% (1/245). Infants with birth weights less than 1,500 g appeared more susceptible to the development of intubation-related laryngeal injury. The conclusion of this study is that endotracheal intubation is an appropriate means of long-term airway management in neonates hospitalized in a pediatric intensive care unit, providing other known risk factors are minimized.

ALTERATIONS IN NEONATAL RESPIRATORY FUNCTION FOLLOWING CHEST PHYSIOTHERAPY

Percussion, suctioning and hyperventilation have been recommended for airway management in neonates requiring endotracheal tubes. To investigate physiological alterations in respiratory function due to chest physiotherapy, we measured arterial blood gases, respiratory patterns, lung mechanics, and functional residual capacity (FRC) in 10 neonates, weights (1.25 to 3.20 kg) during the control period, post vibration of the chest and suctioning, after hyperventilation, and 2 hours post suctioning. Post suctioning compared to controls mean (± SEM) PaO2 decreased 75.2 (± 9.3) to 44.0 (±3.1) mm Hg (P<0.01) while lung compliance and FRC were unchanged. There was a decrease in inspiratory resistance (RI) from 81.8 (± 14.6) to 59.0 (± 10.6) cm H2O/L/sec. (P<0.02) and I:E ratio increased from 0.93 (± 0.04) to 1.04 (± 0.06) (P<0.07). Hyperventilation compared to post suctioning resulted in an increase in mean (± SEM) PaO2 to 63.9 (± 10.0) mmHg (P<0.01), and RI to 98.3 (± 22.0) cm H2O/L/sec. (P<0.05). FRC, CL, VT were unchanged. Two hour followup values for all parameters studied were similar to control values except for a trend toward increased compliance. There were no significant differences at any stage of the study for PaCO2, pH, base excess, VT, or minute ventilation. This study indicates that there is a significant decrease in PaO2 after chest vibration and suctioning increase in PaO2 after hyperventilation but these changes do not appear to be related to alterations in lung volume.