1Department of Anesthesia, St. Jude Children's Research Hospital, 2Department of Anesthesia, Children's Hospital of Michigan, 3Department of Anesthesiology, Children's Hospital of Michigan
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Kaddoum, R. N., Ahmed, Z., D'Augsutine, A. A., Zestos, M. M. Guidelines for Elective Pediatric Fiberoptic Intubation. J. Vis. Exp. (47), e2364, doi:10.3791/2364 (2011).
Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.
1. Equipment Preparation
2. Additional Equipment
3. Patient Preparation
4. Actual Fiberoptic Intubation
5. Representative Results
This video shows an efficient technique for elective fiberoptic intubation in pediatric patients that is easily teachable to residents and fellows and reproducible. The main key is to maintain spontaneous ventilation at all times. Good equipment preparation before hand is also important.
Fiberoptic intubation in pediatric patients with difficult airway could be a challenging task1,2 and the presence of craniofacial dysmorphisms presents additional challenges to tracheal intubation3. It is more difficult to perform this procedure in pediatric patients than in adults mainly because of smaller airways in pediatric patients which make the manipulation of the fiberoptic more difficult since any small movement of the tip of the firberoptic scope runs the risk of touching the mucosa of the nasopharynx/trachea. This will prevent good visualization of the airways and lead to perform back and forth maneuvers of the fiberoptic scope to get better image. While trying to work around this problem, children have higher rates of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated. The anesthesiologist will have to interrupt the procedure to start ventilation and avoid severe desatruation of the patient. Awake fiberoptic intubation is recommended for intubation of patients with difficult airways4. Although this is feasible in adult patients, it is more difficult to perform on pediatric patients while awake because of lack of cooperation5. Some practitioners perform fiberoptic intubation on anesthetized and paralyzed patients2,6. Although acquiring fiberoptic intubation skills in anesthetized patients rather than awake patients is well supported in the literature7-9, it is still a learning curve and in the hands of an inexperience practioner, runs the risk of patient desaturation which could have severe consequences if the patient has difficult airways and is difficult to ventilate or intubate10. We developed guidelines to perform a safe fiberoptic intubation while the patient keeps breathing spontaneously during the procedure and thus avoids the risk of desaturation.
No conflicts of interest declared.
This work is funded by the department of anesthesiology at children's hospital of Michigan.
|Med fusion pump for propofol infusion|
|Fentanyl 0.5-1.0 mcg/kg|
|12F red rubber suction catheter|
|Glycopyrrolate 0.1-0.2 mg|
|Metal insufflation hook|
|Afrin nasal spray|
|Lidocaine 2% or 4% for spraying nares|