Wariya Sukhupragarn

Preoperative Endoscopic Airway Examination (PEAE) Provides Superior Airway Information and May Reduce the Use of Unnecessary Awake Intubation

BACKGROUND:Development of a perioperative plan for management of patients with airway pathology is a challenge for the anesthesiologist. Lack of comprehensive information regarding the architecture of airway lesions often leads the clinician to consider techniques of awake intubation (AI) to avoid catastrophic outcomes in this population. In one uncontrolled trial, endoscopic visualization of the airway lesion was included in the preoperative anesthetic assessment for planning of airway management. We sought to determine whether visual inspection of airway pathology would change the anesthesiologists approach to the management of these patients. METHODS:Patients presenting for elective diagnostic or therapeutic airway procedures were included in the study. After a standard examination of the airway, a management plan was recorded. Before entering the operating room, and after brief preparation of the nares with a vasoconstrictor and local anesthetic, the patients underwent a preoperative endoscopic airway examination (PEAE) and a final airway management plan was recorded and implemented. Four or more months after the procedure, video recordings of the PEAE were reviewed without other patient identifiers and a remote PEAE plan was recorded, to test for operator bias. RESULTS:One hundred thirty-eight patients were studied. Although AI was initially planned in 44 patients, only 16 of these patients underwent preinduction airway control after PEAE (P > 0.05). Additionally, of the 94 patients for whom the initial plan was airway control after the induction of anesthesia, 8 patients were found to have unexpectedly severe airway pathology on PEAE, and also underwent AI. There was no significant difference between the post-PEAE airway management plan and the remote plan recorded 4 or more months later. CONCLUSIONS:In 26% of the patients studied, PEAE affected the planned airway management. We believe that PEAE can be an essential component of the preoperative assessment of patients with airway pathology; airway visualization reduces the number of unnecessary AIs while providing superior information about the airway architecture. PEAE could be applied to other populations of patients at risk for airway control failure with the induction of anesthesia.

Airway management in a patient with Goldenhar syndrome: a case report

Children with Goldenhar syndrome are known to present airway management challenges for the anesthesiologist. We present the case of a 10-year-old child with Goldenhar syndrome, in whom a flexible Laryngeal Mask Airway (Intavent Orthofix, Ltd, Maidenhead, UK) was successfully used for eye surgery.

Correspondence: Glidescope® intubation after failed fiberoptic intubation

through a laryngeal mask in children. Trauma to the epiglottis and glottis is likely consequences if this is made a practice. Others have cautioned against blind intubation through the classic laryngeal mask in children (2–4). Whether the epiglottis position with the air-Q laryngeal mask consistently and safely allows for blind intubation is undetermined. Our clinical experience is that the air-Q like other laryngeal masks does not consistently provide an unobstructed pathway to the larynx in pediatric patients. Until more data become available, it would be wise to assume that this practice will result in unintended airway trauma. We recommend the use of a flexible fiberoptic scope or other visualization method when intubating through laryngeal masks in infants and small children. J O H N E. F I A D J O E* P A U L A. S T R I C K E R* P E T E K O V A T S I S† *Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA †Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA (email: fiadjoej@email.chop.edu)

Correspondence: Glidescope® intubation after failed fiberoptic intubation: CORRESPONDENCE

through a laryngeal mask in children. Trauma to the epiglottis and glottis is likely consequences if this is made a practice. Others have cautioned against blind intubation through the classic laryngeal mask in children (2–4). Whether the epiglottis position with the air-Q laryngeal mask consistently and safely allows for blind intubation is undetermined. Our clinical experience is that the air-Q like other laryngeal masks does not consistently provide an unobstructed pathway to the larynx in pediatric patients. Until more data become available, it would be wise to assume that this practice will result in unintended airway trauma. We recommend the use of a flexible fiberoptic scope or other visualization method when intubating through laryngeal masks in infants and small children. J O H N E. F I A D J O E* P A U L A. S T R I C K E R* P E T E K O V A T S I S† *Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA †Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA (email: fiadjoej@email.chop.edu)