Airway challenges in an infant undergoing laser supraglottoplasty for laryngomalacia

Sir, A-three-month-old female infant weighing 2 kg presented with fever, lethargy, and inspiratory stridor, which increased on crying and supine position for the past two weeks. On examination, the infant was drowsy, febrile, tachypnoeic with subcostal and intercostal retraction, and bilateral fine crepitations on auscultation. Her heart rate (HR) was 168/min, respiratory rate (RR) was 58/min, and peripheral oxygen saturation was (SpO2) 88% on room air. Complete blood count and chest X-ray were suggestive of bilateral pneumonia. Infant was diagnosed with grade-3 laryngomalacia on diagnostic endoscopy. As conservative management (proning, non invasive ventilation through nasal mask) failed, child was optimized with antibiotics, nebulization, and oxygen supplementation over one week and was posted for laser supraglottoplasty. After getting informed, high-risk consent, infant was fasted, 4 h of breast milk and 2 h for clear fluids. Infant was shifted to operation theatre with oxygen at 2L/min via a nasal prong. Difficult airway cart including tracheostomy tube was kept ready and monitors were connected. Her base line vitals were: HR—154/min; SpO2—92% on room air; RR—52/min. Ringer's lactate was started according to body weight requirements. Two experienced anaesthesiologists were made available. Infant was pre-oxygenated for three minutes with 100% oxygen and was pre-medicated with injection glycopyrrolate 8 μg, midazolam 0.06 mg, fentanyl 5 μg, and dexamethasone 0.2 mg. Anaesthesia was induced with a graded increase in sevoflurane concentration while maintaining spontaneous ventilation. Direct laryngoscopy and intubation was attempted using size 0 miller blade with a shoulder pad, but failed due to Cormack-Lehane (CL) grade of class 3a [Figure 1]. Second attempt of intubation was tried with a zero degree rigid endoscope of size 2.7 mm by the otolaryngologist but it did not improve the CL grade. External laryngeal manipulation was also applied. Eventually, a rigid bronchoscope of size 3.5 was used to lift the floppy epiglottis and an intubating bougie of size 3 mm loaded with an uncuffed polyvinyl chloride endotracheal tube (ETT) of internal diameter 3.5 mm ID was passed within 15 minutes of the initial attempt. After confirmation of endotracheal tube placement, injection atracurium (1 mg) was administered and anaesthesia was maintained with oxygen and sevoflurane. Nitrous oxide was avoided and a saline syringe was made available as fire precaution during the laser surgery. Supraglottoplasty was done using diode laser [Figure 2]. The surgery lasted for 2 h. Intra-operatively patient was stable and was shifted to the pediatric intensive care unit for postoperative mechanical ventilation after the procedure. Infant was successfully extubated on the third postoperative day with an emergency tracheostomy arranged as a stand by.Figure 1: Grade III laryngomalaciaFigure 2: Laser surgery following endotracheal intubationLaryngomalacia is the most common congenital cause of upper airway obstruction in infants with presentation usually within two weeks of birth.[1,2] Short aryepiglottic folds, redundant arytenoid tissue, and a long curled epiglottis characterize the condition. Supraglottoplasty is the well-known surgical treatment for laryngomalacia.[3] Anaesthetic management of patients with laryngomalacia is challenging due to anticipated difficult airway. Anaesthetic techniques that maintain spontaneous ventilation need to be used till the airway is secured.[4,5] Premedication is essential to prevent vagal responses and sialation. Mild sedation prevents the child from crying and hyperventilating as it may worsen the stridor. Laryngomalacia may make mask ventilation a challenge as the airway may collapse when the muscle tone is lost following induction. Endotracheal intubation of patients with laryngomalacia is difficult due to the large lax overhanging epiglottis. Inhalational induction is preferred and neuromuscular blockade is preferably avoided till the airway is secured with ETT.[6] Video laryngoscopy with pediatric scope is another novel method for difficult intubation if available. Apnoeic and jet ventilation are other methods of anaesthesia. Effective plan for extubation should be made to prevent cannot intubate and cannot ventilate situation. As laryngomalacia may lead to severe respiratory distress in pediatric age group and supraglottoplasty being an emerging procedure, our case report brings out the problem that can be encountered with a anticipated difficult airway and a safe way of securing the same. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s), parent has/have given his/her/their consent for child images and other clinical information to be reported in the journal. The parent of the child understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.