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... Grade 1 and 2 are < 50% and 51-70% obstruction respectively, grade 3 is 71-91% obstruction, while there is no detectable lumen in grade 4(6)(9). Only higher grades require intervention with either multiple sessions of dilatation with coronary angioplasty catheter under fluoroscopy (not available at our set-up) or tracheloplasty (6). Also, endoscopic dilatation may damage the exposed cartilage and lead to scarring and exacerbate the stenosis (10). ...
Introduction: In neonates with an unanticipated difficult airway, there is an increased probability of failed intubation even with highly trained hands while performing direct laryngoscopy. Aims: We describe our experience of using a modified infant feeding tube (IFT) as an indigenous endotracheal tube (ETT) in a series of paediatric surgical patients with congenital subglottic stenosis (SGS). Material and Methods: A retrospective study was performed in our institute from January 2018 to December 2019. ETT with modified 6 and 8 French (Fr) sized IFT’s were used. A stylet obtained from the VP shunt system was used to aid in intubation. Results: Out of 12,500 admissions in our department, there were 5 pediatric cases with SGS which were managed using modified IFT. Four were neonates and 1 infant (M:F = 2:3). Modified IFT(s) were used after failed intubation with ETT of size 2.5 mm in 4 patients (non-availability of ETT of size 2 mm), while in one neonate, even 2 mm ETT could not be negotiated due to SGS. In all the 5 children, successful intubation was finally performed with modified 8 French (Fr) IFT in 3, and with modified 6 Fr IFT in two cases. The surgical procedure was completed in 4 neonates out of 5 cases, while in one infant it was deferred due to the clinical condition of the patient and significant SGS. Conclusion: All 5 patients with SGS were managed without performing a tracheostomy. Modified IFT(s) is an effective alternative if smaller sized ETT(s) cannot be negotiated or unavailable in difficult neonatal and paediatric airway. This modified IFT as ETT has to be an important part of the emergency airway tray. It should not be considered as a replacement for routine use of standard ETT.
... A decision was taken by the surgeons to postpone the surgery as it was not a frank obstruction and obtaining a safe secure airway gained precedence. In another case scenario described by Kundal R et al., a similar airway anomaly was encountered [13]. However, the surgery required in that neonate was an emergency and thus the patient was intubated with a feeding tube and attached to JR circuit. ...
Preterm neonates are defined as those born before 37 weeks. The anatomical features of preterm neonates vary from that of an
adult, such that they have a large tongue, an anterior funnel shaped larynx, angled vocal cords and an omega shaped epiglottis. Their
physiological development also differ as they have a greater risk for apnoea of prematurity, airflow obstruction, bronchopulmonary
dysplasia, low functional residual capacity and decreased transient oxygen tension. Congenital airway anomalies have a prevalence
rate of 0.2-1 in 10,000 live births. Congenital Tracheal Stenosis (CTS) caused by complete tracheal rings is one of the rarest forms
of all the airway anomalies that occur, which is characterised by presence of complete ‘O’ shaped cartilaginous rings of trachea
devoid of a membranous part. The case discussed in the article is that of a day 26 preterm neonate with increasing abdominal
distension and failure to thrive. The neonate was posted for an urgent exploratory laparotomy for abdominal decompression and
ileostomy. Patient was kept on Continuous Positive Airway Pressure (CPAP) support for four days immediately after birth; however,
intubation was never attempted nor required. With a history of respiratory depression and lack of history of previous intubation,
difficult airway cart was kept ready prior to surgery. Supraglottic Airway (SGA) devices were at the core of airway rescue in this case
of undiagnosed CTS. This case report shows how and why a preparation for difficult airway in preterm neonates is a necessity. It
will provide as a guide if a similar case is encountered by the anaesthetist.
... However, intraoperatively, the tube was dislodged, re-intubation attempts were unsuccessful and patient developed cardiac arrest [4]. Kundal [5] and associates have reported a similar emergency where in they have made use of a 6 Fr infant feeding tube passed beyond the vocal cords. They attached a Jackson rees' modification of Ayre's T-piece to this infant feeding tube with the help of connector of a 3.5 ETT and completed a primary repair of TEF with such assembly used for ventilation. ...
Subglottis stenosis is a real nightmare situation for
anaesthetist more so in a neonate. We came across such
an emergency of unanticipated difficult intubation in a
case of type D tracheoesophageal fistula. We managed
the situation with surgical tracheostomy with use of
endotracheal tube. There are limited references of
managing such emergency in a newborn in the present
literature. We have also discussed other means of
managing such situation.
... [6] Sir, Unanticipated difficult airway and absence of guidelines for its management in neonates is a piquant situation for an anesthetist. [1,2] Presentation of congenital subglottic stenosis (SGS) in neonates may vary from asymptomatic to frank stridor. [3] We present rescue airway management of a 2-day-old newborn who presented with intestinal obstruction secondary to high anorectal malformation. ...
... C ongenital high airway obstruction syndrome (CHAOS) is caused by defective canalisation of the upper airways around the 10 th week of gestation (1). Congenital subglottic stenosis is one of the aetiologies of CHAOS, with an incidence of <0.2% (2). Antenatally undiagnosed subglottic stenosis can present as an emergency that requires resuscitation at birth, and in this scenario, 'cannot intubate, cannot oxygenate' situation can be disastrous. ...
Unanticipated difficult airway in a neonate is a challenging situation with many difficulties because of inherent anatomical variations. To complicate the situation there is a lack of appropriate equipment, expertise and established guidelines on the management of difficult airway in neonates and infants. There are few published reports regarding the use of available devices for emergency front-of-neck access. We report the case of airway management of a neonate with an unanticipated finding of subglottic stenosis. Subglottic stenosis is one of the aetiologies of congenital high airway obstruction syndrome, which may be diagnosed antenatally based on ultrasonography findings.
... Successful intubation with ETT made from feeding tube of 6 Fr size has been reported for a TOF repair. [2] However, we find the material of feeding tube to be soft and pliable compared to standard ETT and has a risk of dislodgement and occlusion of the lumen of the tube during surgery. Another proposed option for airway management in SGS is to dilate the stenotic segment with Fogarty catheter and then pass ETT. ...
