Letters to the Editor: Letters & Announcements
To the Editor:
A 6-mo-old infant (body weight 5 kg) with Boring-Opitz syndrome, a rare complex of malformations that includes malformed skull and facial bones (1), presented for removal of an infected port system. There was a history of two previous difficult tracheal intubations.
Anesthesia was induced with increments of propofol until loss of consciousness. The ability to manually ventilate the lungs was confirmed before more propofol was administered. A Size 1 laryngeal tube S-II (LT-S) (VBM Medizintechnik, Sulz a.N., Germany) was inserted and proper position confirmed using capnography and chest auscultation (Fig. 1). Thereafter, nasal fiberoptic tracheal intubation was performed with a flexible pediatric fiberscope (2.8 mm diameter) armed with a 4.0 mm ID endotracheal tube. When the proximal cuff of the LT-S was seen in the pharynx, it was briefly deflated allowing the bronchoscope to pass. Once tracheal rings were identified, the cuffs of the LT-S were again deflated, the endotracheal tube passed over the fiberscope into the trachea and correct position confirmed by bronchoscopy and capnography. The LT-S was then removed from the airway.
The LT-S is a supraglottic ventilatory device available in pediatric sizes appropriate for use in infants and neonates with a body weight of less than 5 kg. With its distal balloon inflated in the esophagus and a gastric drain tube advanced through a side-port, the likelihood of gastric inflation, and regurgitation is reduced (2). In this case, adequate ventilation could be maintained throughout the entire procedure, apart from two short periods of cuff deflation during initial advancement of the fiberscope and endotracheal tube placement. The bronchoscope had to be passed alongside the LT-S rather than through its lumen, because a flexible bronchoscope cannot be inserted through the ventilation orifices of a Size 1 LT-S. On the other hand, bronchoscopy alongside the LT-S improved localization of the glottic area because the LT-S acted as a landmark that could be followed with the fiberscope, thereby reducing the risk of “getting lost” in the airway. Four other cases using the technique described above have subsequently been uneventfully performed.
Gösta Lotz, MD
Richard Schalk, RN
Christian Byhahn, MD
Department of Anesthesiology, Intensive Care Medicine, and Pain Management
J. W. Goethe-University Medical School
1. Boring A, Silengo M, Lerone M, Superneau DW, Spaich C, Braddock SR, Poss A, Opitz JM. Severe end of Opitz trigonocephaly (C) syndrome or new syndrome?. Am J Med Genet 1999;85:438–46
2. Genzwuerker HV, Fritz A, Hinkelbein J, Finteis T, Schlaefer A, Schaeffer M, Thil E, Rapp HJ. Prospective, randomized comparison of laryngeal tube and laryngeal mask airway in pediatric patients. Paediatr Anaesth 2006;16:1251–6