LETTERS TO THE EDITOR: Letters & Announcements
To the Editor:
Ianolli and Litman (1) reported a case of tension pneumothorax during flexible fiberoptic bronchoscopy through an endotracheal tube (ETT) in a neonate with tracheoesophageal fistula (TEF). A rigid ventilating bronchoscope (2–4) or its rod lens (5) can also be used to perform airway endoscopy and, if necessary, insert a Fogarty™ catheter into the TEF. We describe here another safe technique:
- inhalational induction with sevoflurane in O2, taking care to maintain spontaneous ventilation
- laryngoscopy for topical anesthesia of the larynx and upper trachea with lidocaine
- insertion of a nasopharyngeal airway to provide O2 and sevoflurane during endoscopy
- oral insertion of a Hopkins® straight forward telescope (OD 1.9 mm) ( K. Storz, Germany) adapted to a camera to allow the surgeon and the anesthesiologist to share the operator’s findings
- after endoscopy, endotracheal intubation and positioning of the ETT according to the result of the endoscopy to allow controlled ventilation without gastric inflation.
The advantages of this technique are:
- visualization of the larynx and trachea during spontaneous ventilation without the presence of an ETT
- preoperative diagnosis of laryngeal cleft, laryngomalacia, or tracheomalacia (36% of cases) (6)
- preoperative diagnosis of tracheobronchial anomalies (47% of cases), an ectopic right upper bronchus being the most frequent (6)
- precise localization of the TEF; in Holski’s series, the TEF was at or below the carina in 11% of cases, within 1 cm of the carina in 22 %, and above this in 67%(5)
- diagnosis of the presence of a second TEF, e.g., at the cervical level
Although no studies have been published regarding the influence of preoperative endoscopy on the outcome of neonates with TEF, any of the above-mentioned anomalies can result in significant perioperative morbidity (e.g., difficult oxygenation/ventilation, failed extubation, atelectasis, reoperation) if its presence is unsuspected. We, therefore, recommend preoperative endoscopy in neonates with TEF.
Francis Veyckemans, MD
Marc Hamoir, MD, PhD
Philippe Rombaux, MD
Luc J. Van Obbergh, MD, PhD
Raymond Reding, MD, PhD
1. Ianolli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg 2002; 94: 512–3.
2. Kosloke AM, Jewell PF, Cartwright KC. Crucial bronchoscopic findings in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 1988; 23: 466–70.
3. Andropoulos DB, Rowe RW, Betts JM. Anaesthetic and surgical airway management during tracheo-oesophageal fistula repair. Paediatr Anaesth 1998; 8: 313–9.
4. Reenes ST, Burt N, Smith CD. Is it time to reevaluate the airway management of tracheoesophageal fistula? Anesth Analg 1995; 81: 866–9.
5. Holski J. Bronchoscopic findings and treatment in patients with tracheo-oesophageal fistula. Paediatr Anaesth 1992; 2: 297–303.
6. Usui N, Kamata S, Ishikawa S, et al. Anomalies of the tracheobronchial tree in patients with esophageal atresia. J Pediatr Surg 1996; 31: 258–62.