The use of high‐flow nasal oxygen during airway management in a child with epidermolysis bullosa dystrophica and a difficult airway

Abstract

Summary The role of high‐flow nasal oxygen in paediatric anaesthesia has been emerging in recent years. However, literature regarding its benefits in paediatric difficult airway management is limited. In this case report, we describe the use of high‐flow nasal oxygen during airway management of a child with a difficult airway due to epidermolysis bullosa dystrophica in whom the use of a facemask would have been potentially harmful. Deep sedation was achieved with propofol and remifentanil while maintaining spontaneous breathing before flexible bronchoscopic tracheal intubation was attempted. However, on attempted tracheal intubation difficulty was encountered due to poor visualisation and contact bleeding. Tracheal intubation was eventually successful after converting to videolaryngoscopy. Oxygenation was maintained throughout the process despite deep sedation and a long procedure time. Moreover, no skin abrasions or mucosal injury resulted from the use of high‐flow nasal oxygen. We conclude that high‐flow nasal oxygen has a valuable role during airway management for a child with a predicted difficult airway when the use of a facemask would have been potentially harmful.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Difficult Airway Management in Adults With Recessive Dystrophic Epidermolysis Bullosa: A Case Series

“…12,13 Recently, a case report described the use of high-flow nasal cannula oxygenation without complications in a pediatric patient with dystrophic epidermolysis bullosa, enabling avoidance of bag-mask ventilation and an unhurried approach to a difficult and fragile airway. 14 Our case series describes similar facilitation of airway management using THRIVE in adults. While airflow models have predicted higher shear stress in the nasal cavity and larynx from high oxygen flow rates compared to normal breathing, the clinical significance of this remains unclear.…”

Anesthesia management in dystrophic epidermolysis bullosa: A case report

“…Silicone-based tape should be applied to the areas where the mask will contact the face. NgLY et al suggested using high flow oxygen as a preferable method instead of a face mask in children with difficult airways since it does not harm the mucosa and the skin [8].…”

Anesthetic Management of Adults With Epidermolysis Bullosa

“…Alternatively, Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) may be used for preoxygenation and apneic oxygenation. 58 This technique employs use of high-flow nasal oxygen cannula placed over petrolatum gauze, reducing the risk of facial trauma from mask ventilation and prolonging the safe apneic time during difficult intubation. 58,59 Careful fiber-optic intubation with a well-lubricated, small endotracheal tube (size 5.0-or 6.0-mm internal diameter) is the recommended technique for airway management and carries the least risk of trauma to the airway.…”

“…58 This technique employs use of high-flow nasal oxygen cannula placed over petrolatum gauze, reducing the risk of facial trauma from mask ventilation and prolonging the safe apneic time during difficult intubation. 58,59 Careful fiber-optic intubation with a well-lubricated, small endotracheal tube (size 5.0-or 6.0-mm internal diameter) is the recommended technique for airway management and carries the least risk of trauma to the airway. 2,40,51 Oral airways and other intubating guides should be avoided due to the risk of shear force trauma.…”