Extubation and endotracheal tube exchange using a guidewire sheath in management of difficult pediatric airways

Abstract

occur and create a cannot ventilate, cannot intubate scenario (5). When a tube with an intubating stylet can not inserted into the glottis by two to three attempts under the left paraglossal laryngoscopy in the CL ⁄ P children, therefore, we often combine some other measures to achieve successful intubation and safe airway management: (i) Combined use of the left paraglossal laryngoscopy and lightwand technique is often our first line option. Under the guide of laryngoscopy, the lightwand may easily be positioned at the laryngeal aperture according to transillumination of soft tissues of the anterior neck. When the cricothyroid membrane is transilluminated, the ETT is inserted into the trachea along the lightwand; (ii) The gum elastic bougie guided intubation described by Semjen et al. (6) is another useful alternative. Before insertion of the gum elastic bougie, the child's head is rotated to the right to improve visualization while applying external laryngeal pressure displacing the larynx to the left. Because a gum elastic bougie is longer than a styletted ETT, it can be manipulated without occluding the laryngeal view by the anesthetist right hand. Also the smaller diameter of a gum elastic bougie compared to the styletted ETT may decrease the interference to the restricted laryngeal view under the left paraglossal laryngoscopy. Additionally, our experience suggests that compared with the left paraglossal laryngoscopy using a Miller blade, the left paraglossal laryngoscopy using a same size Macintosh blade can make insertion of the lightwand or gum elastic bougie easier because the Macintosh blade with a curved tongue spatula and a winder flange can make a larger room for device manipulation, and (iii) If the above measures fail, the fiberoptic intubation under the left paraglossal laryngoscopy is a favorable selection of airway rescue, especially for when the laryngeal view is C&L class 4. We find that use of the left paraglossal laryngoscopy can provide a clear airway for the fiberscopy and allow identification of laryngeal structures using the fiberoptic bronchoscope.It must be emphasized that when intubation with the left paraglossal laryngoscopy fails and subsequently facemask ventilation is difficult, a laryngeal mask airway should be immediately inserted. Then the fiberoptic intubation is performed through it (7).Finally, we agree the authors' view that the left paraglossal laryngoscopy technique needs to be practiced in children with a normal upper airway before using it for airway management of the bilateral CL ⁄ P children.

A Child With a Difficult Airway

“…37,38 Conversion from oral intubation to nasal intubation in children has also been described. A number of reports have been published using various devices in innovative ways (non-FDA approved) to serve as an exchange catheter in preparation for a potential reintubation.…”