Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Abstract

Introduction:In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure.Symptoms and clinical findings:A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios.Therapeutic intervention and outcomes:After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0–3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5–1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally.Conclusion:The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

Airway management for neonates requiring ex utero intrapartum treatment (EXIT)

“…In preparation to secure the fetal airway, fetal equipment, monitors, and medications should be readily available. Equipment and medications that may be needed for an EXIT procedure are listed in Table …”

“…The options for airway intervention include direct laryngoscopy, video laryngoscopy, rigid bronchoscopy, fiberoptic intubation via laryngeal mask airway, tracheotomy with retrograde wire orotracheal intubation technique, tracheostomy, mass decompression or partial resection, or ECMO …”

“…If an adequate view of the larynx is not obtained or if there is concern for distal airway compression, then a rigid bronchoscopy should be performed. The use of video laryngoscopy during an EXIT has been described; however, preservation of the sterile field remains paramount and may be challenging with the use of a video laryngoscope. Even with successful intubation, the mass can occasionally cause compression that is severe enough to impair ventilation.…”

Ex utero intrapartum treatment (EXIT) procedure: Indications and procedural considerations

“…Direct laryngoscopy or the use of glidescope video laryngoscope 1 was the first step in the majority of cases, followed by rigid or fibreoptic bronchoscopy and, if these fail, tracheostomy. Byun et al 1 explained the glidescope video laryngoscope is useful in neonates as it has a 60-degree angulated blade and digital camera and they successfully used this. Alternatively, Braden et al 2 were unable to visualise the glottic opening with the glidescope.…”

“…Ex utero intrapartum treatment (EXIT) procedure is performed when there is airway compromise in the fetus 1 . Braden et al 2 describe it as a modified caesarean birth, where the fetus is partially delivered in order to secure the airway or commence extra corporeal membrane oxygenation (ECMO) while oxygenation to the fetus is maintained via uteroplacental circulation.…”