A generalized multistage approach to oral and nasal intubation in infants with Pierre Robin sequence: A retrospective review

• Published in: Pediatric anesthesia 2018-11, Vol.28 (11), p.1029-1034
• Main Authors: Templeton, T. Wesley, Goenaga‐Díaz, Eduardo J., Runyan, Christopher M., Kiell, Eleanor P., Lee, Amy J., Templeton, Leah B.
• Format: Article
• Language: English
• Subjects: Airway management; Airway Management - methods; Airway Obstruction; Anesthesia, General - methods; Fiber Optic Technology; general anesthesia; Humans; Infant; Infant, Newborn; Intubation; Intubation, Intratracheal - methods; Laryngeal Masks; Ostomy; Patients; Pierre Robin syndrome; Pierre Robin Syndrome - physiopathology; pulmonary ventilation; Retrospective Studies; Sevoflurane - therapeutic use
• ISSN: 1155-5645; 1460-9592
• DOI: 10.1111/pan.13499

Summary Background Airway management in children with Pierre Robin sequence in the infantile period can be challenging and frequently requires specialized approaches. Aims The aim of this study was to review our experience with a multistage approach to oral and nasal intubation in young infants with Pierre Robin sequence. Methods After IRB approval, we reviewed 13 infants with Pierre Robin sequence who underwent a multistage approach to intubation in the operating room for mandibular distractor or gastrostomy tube placement. All patients underwent awake placement of either an LMA‐Classic™ #1 or ProSeal™ laryngeal mask airway size #1. General anesthesia was induced with sevoflurane, and patients were relaxed with rocuronium. The laryngeal mask airway was replaced with an air‐Q® 1.0. Children were then intubated through the air‐Q® 1.0 using a flexible fiberoptic bronchoscope. In cases that required a nasotracheal tube, the oral tube was left in place while a flexible fiberoptic bronchoscope loaded with a similar internal diameter nasal Ring‐Adair‐Elwyn (RAE) tube was introduced into the nares. Once the scope was in proximity to the glottis, the oral tube was removed and the patient was intubated with the nasal RAE over the fiberscope. Results All 13 patients with Pierre Robin sequence were successfully intubated. We observed no periods of desaturation during placement and induction with the LMA‐Classic™ or ProSeal™ laryngeal mask airway except in one patient who was in extremis in the neonatal intensive care unit and required emergent transport to the operating room with the laryngeal mask airway in place. We observed several brief periods of desaturation during the apneas associated with fiberoptic intubation. Conclusion In conclusion, we were able to use a ventilation‐driven, multistaged approach using the unique properties of different supraglottic airways to facilitate oral and nasal intubation in 13 infants with Pierre Robin sequence.