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Modified lightwand intubation in a child with spondyloepiphyseal dysplasia congenita
Acta Anaesthesiologica Taiwanica 49 (2011) 66e68
Contents lists available at ScienceDirect
Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com
Case Report
Modified lightwand intubation in a child with spondyloepiphyseal dysplasia congenitay,z Chih-Peng Lin, Chang-Fu Su, Wen-Ying Lin, Jing-Yi Jan, Chuen-Shin Jeng, Feng-Sheng Lin, Shou-Zen Fan* Department of Anesthesiology, National Taiwan University, College of Medicine and Hospital, Taipei, Taiwan, R.O.C.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 May 2010 Received in revised form 25 February 2011 Accepted 2 March 2011
This is the case report on a 1-year 9-month-old boy suffering from spondyloepiphyseal dysplasia congenita who was successfully intubated with our modified lightwand intubation procedure for general anesthesia to undergo bilateral herniorrhaphy despite the great likelihood of facing a difficult airway because of unstable cervical spine. We bent the pediatric wand after it was encased in an endotracheal (ET) tube of appropriate diameter. The light tip of the wand was let to protrude just out of the bevel of the ET tube. Once the light bulb properly transilluminated the trachea, the ET tube was threaded gently into the trachea. The patient recovered from anesthesia smoothly and was discharged on the next day. This maneuver can facilitate both visual and tactile confirmations of the position and proper tube size. The effectiveness and safety of our modified lightwand intubation procedure is well demonstrated. Copyright Ó 2011, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
Key words: cervical vertebrae; intratracheal; intubation
1. Introduction Spondyloepiphyseal dysplasia congenita (SDC) is a rare autosomal dominant genetic disorder of dwarfism involving the vertebral column and epiphyses of long bones. Because these patients have short necks with limited flexion and odontoid hypoplasia with atlantoaxial instability,1 airway management is challenging. Although fiberoptic intubation remains the gold standard for pediatric difficult airway management, there are few reports recommending that lightwand intubation is also a good alternative.2 To date, however, there is no report on the use of lightwand to manage difficult airway in a pediatric patient with dwarfism and unstable cervical spine. We share our experience in successful intubation in a child with SDC with our newly developed modified lightwand intubation procedure.
2. Case report A 1-year 9-month-old boy with SDC was scheduled for bilateral herniorrhaphy. He stood only 78 cm (3e10 percentile) and weighed
11.2 kg (10e25 percentile). Physical examination revealed hypertelorism, low hairline, short neck, and thoracic kyphoscoliosis. Bony crepitus with neck movement was also noted. Radiographic examination revealed scoliosis of thoracolumbar spine with decreased vertebral body height. Poor ossification of odontoid process and atlantoaxial subluxation were also noted (Fig. 1). General anesthesia was induced with 55 mg of thiopental. After demonstrating that the lungs could be easily ventilated by bag and mask without neck extension or flexion, 25 mg of succinylcholine was given to facilitate endotracheal (ET) intubation. A specially designed pediatric lightwand (Trachlight; Laerdal Medical Corporation, Wappingers Falls, NY, USA) encased in a lubricated uncuffed ET tube (Kendall, ID: 5.0 mm) with the lighting tip protruding just beyond the bevel of the ET tube was inserted (Fig. 2). After the location of the light bulb was confirmed in the trachea, the ET tube was threaded gently into the trachea. During the whole intubation process, there was no neck movement. Intraoperative course was uneventful, and the patient was extubated while he was still deeply anesthetized and he recovered from anesthesia smoothly. He was discharged on the next day. 3. Discussion
* Corresponding author. Department of Anesthesiology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan, R.O.C. E-mail: [email protected] (S.-Z. Fan). y There is no conflict of interest. z Support was provided solely from institutional and/or departmental sources.
Lightwand intubation technique needs less manipulation of C-spine movement in sharp contrast to direct laryngoscopy3 and has been used successfully in adult patients with cervical spine injury.4 Although lightwand intubation procedure is considered
1875-4597/$ e see front matter Copyright Ó 2011, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.aat.2011.05.003
Modified lightwand intubation of children
67
Fig. 1. Cervical spine X-ray, lateral view. Left film shows decreased vertebral body height and short neck. Right film shows atlantoaxial subluxation (arrow).
a safe and effective alternative way for tracheal intubation in pediatric patients,5 there is limited information to date about managing unstable cervical spine in infants or children with the lightwand intubation technique. In enclosing the light stylet in the ET, it is suggested that the tip of the stylet is anchored just inside the tracheal tube.6 Usually, in the adult patients, the glottic opening is much bigger than the outer diameter of the ET tube used. In pediatric patients, the reasons for the failure of lightwand intubation (inappropriately large ET tube, truly difficult tracheal entry, or other technical problems) are difficult to differentiate.7 To remedy these ambiguous drawbacks in lightwand intubation usage in complicated situations, we modify the lightwand intubation procedure. We bend the pediatric light wand, which is enclosed in the lubricated ET approximately to 80 in “hockey-stick” formation. The bend takes approximately at the base of the tongue along the patient’s profile such that the stylet tip is at the level of the
Fig. 2. Photograph of modified lightwand endotracheal (ET) tube assembly. The pediatric wand (Trachlight) was bent to around 80 “hockey-stick” formation. The bend was made at approximately the base of the tongue along the patient’s profile, such that the stylet tip was at the level of the laryngeal inlet when the proximal portion was situated in the oropharynx. An uncuffed tracheal tube (of diameter selected on the basis of the patient’s age) was then mounted on the pediatric lightwand with the tip of the light stylet protruding beyond the ET tube. The wand light tip was left naked by placing the ET tube just below the bending site (arrow).
laryngeal inlet when the proximal portion is situated in the oropharynx.8 The lighting tip of the wand is left to protrude the ET tube just below the bending site. The assembled lightwand is inserted so that the naked tip of the light stylet is made to enter the trachea first and then the ET tube is gently threaded into the trachea. Entry into the glottic opening in pediatric patients is much easier using a naked wand tip alone than a conventional tube wand assembly. Once the light stylet transilluminates the trachea at proper position, we have overcome the difficulty of trachea entry. Failed intubation because of an oversized ET tube can be easily detected by the unusual resistance encountered when threading the ET tube. This maneuver can also reduce trauma to the glottic structure caused by repeated trials. Our modified lightwand intubation procedure can give both visual and tactile confirmation of the proper tube size and position. In clinical studies, there is no evidence of burn injuries caused by conventional use of Trachlight. As for our modification, the risk of tracheal mucosal burn caused by modified lightwand intubation procedure could be very low. The reasons are as follows. Modified lightwand intubation can mostly be completed in less than 30 seconds, following the first blink of Trachlight. Animal study has also demonstrated that the trachea mucosa is not injured even by a 250-second focused Trachlight tip exposure.9 In clinical practice, the tip of the lightwand is on moving rather than fixed stationarily at a single location on the tracheal mucosa. Further investigation about safety and efficacy will be done in the near future. There are few previous reports on the anesthetic management of SDC.10e12 Although successful tracheal intubation by direct laryngosopy has been reported,12 Redl13 reported the case of a young patient with SDC in whom massive pyramidal tract signs developed after direct laryngoscopic tracheal intubation, resulting in mortality. In our case, the anticipated difficult airway and possibly unstable cervical spine was successfully managed by using modified lightwand intubation without neck movement. In surgically treated children with dwarfism and unstable cervical spine, the objective of airway management is to prevent neck movement. The safest way to approach this objective, as considered, is to have the patient intubated fiberotically under deep general anesthesia facilitated by maintaining ventilation and anesthesia first with a nasopharyngeal airway. However, fiberoptic intubation requires expensive equipment and a high level of skill.
68
In conclusion, we successfully intubated a child with SDC with difficult airway and unstable cervical spine by a modified lightwand intubation procedure. When managing pediatric patients with possibly unstable cervical spine, such as trauma victims, rheumatoid arthritis, Down’s syndrome, and so on, the use of modified lightwand intubation should be considered as a safer intubation alternative than direct laryngoscopy. References 1. Miyoshi K, Nakamura K, Haga N, Mikami Y. Surgical treatment for atlantoaxial subluxation with myelopathy in spondyloepiphyseal dysplasia congenita. Spine (Phila Pa 1976) 2004;29:E488e91. 2. Xue FS, Yang QY, Liao X, He N, Liu HP. Lightwand guided intubation in paediatric patients with a known difficult airway: a report of four cases. Anaesthesia 2008;63:520e5. 3. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005;101:910e5. 4. Weis Jr FR. Light-wand intubation for cervical spine injuries. Anesth Analg 1992;74:622.
C.-P. Lin et al 5. Holzman RS, Nargozian CD, Florence FB. Lightwand intubation in children with abnormal upper airways. Anesthesiology 1988;69:784e7. 6. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg 2000;90:745e56. 7. Fisher QA, Tunkel DE. Lightwand intubation of infants and children. J Clin Anesth 1997;9:275e9. 8. Chen TH, Tsai SK, Lin CJ, Lu CW, Tsai TP, Sun WZ. Does the suggested lightwand bent length fit every patient? The relation between bent length and patient’s thyroid prominence-to-mandibular angle distance. Anesthesiology 2003;98: 1070e6. 9. Nishiyama T, Matsukawa T, Hanaoka K. Safety of a new lightwand device (Trachlight): temperature and histopathological study. Anesth Analg 1998;87: 717e8. 10. Tofield CE, Mackinnon CA. Cleft palate repair in spondyloepiphyseal dysplasia congenita: minimizing the risk of cervical cord compression. Cleft Palate Craniofac J 2003;40:629e31. 11. de Boer HD, Hemelaar A, van Dongen R, Gielen MJ. Successful epidural anaesthesia for Caesarean section in a patient with spondyloepiphyseal dysplasia. Br J Anaesth 2001;86:133e4. 12. Mogera C, Muralidhar V. Spondyloepiphyseal dysplasia congenita syndrome: anesthetic implications. Anesth Analg 1996;83:433e4. 13. Redl G. Massive pyramidal tract signs after endotracheal intubation: a case report of spondyloepiphyseal dysplasia congenita. Anesthesiology 1998;89: 1262e4.
Contents lists available at ScienceDirect
Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com
Case Report
Modified lightwand intubation in a child with spondyloepiphyseal dysplasia congenitay,z Chih-Peng Lin, Chang-Fu Su, Wen-Ying Lin, Jing-Yi Jan, Chuen-Shin Jeng, Feng-Sheng Lin, Shou-Zen Fan* Department of Anesthesiology, National Taiwan University, College of Medicine and Hospital, Taipei, Taiwan, R.O.C.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 May 2010 Received in revised form 25 February 2011 Accepted 2 March 2011
This is the case report on a 1-year 9-month-old boy suffering from spondyloepiphyseal dysplasia congenita who was successfully intubated with our modified lightwand intubation procedure for general anesthesia to undergo bilateral herniorrhaphy despite the great likelihood of facing a difficult airway because of unstable cervical spine. We bent the pediatric wand after it was encased in an endotracheal (ET) tube of appropriate diameter. The light tip of the wand was let to protrude just out of the bevel of the ET tube. Once the light bulb properly transilluminated the trachea, the ET tube was threaded gently into the trachea. The patient recovered from anesthesia smoothly and was discharged on the next day. This maneuver can facilitate both visual and tactile confirmations of the position and proper tube size. The effectiveness and safety of our modified lightwand intubation procedure is well demonstrated. Copyright Ó 2011, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
Key words: cervical vertebrae; intratracheal; intubation
1. Introduction Spondyloepiphyseal dysplasia congenita (SDC) is a rare autosomal dominant genetic disorder of dwarfism involving the vertebral column and epiphyses of long bones. Because these patients have short necks with limited flexion and odontoid hypoplasia with atlantoaxial instability,1 airway management is challenging. Although fiberoptic intubation remains the gold standard for pediatric difficult airway management, there are few reports recommending that lightwand intubation is also a good alternative.2 To date, however, there is no report on the use of lightwand to manage difficult airway in a pediatric patient with dwarfism and unstable cervical spine. We share our experience in successful intubation in a child with SDC with our newly developed modified lightwand intubation procedure.
2. Case report A 1-year 9-month-old boy with SDC was scheduled for bilateral herniorrhaphy. He stood only 78 cm (3e10 percentile) and weighed
11.2 kg (10e25 percentile). Physical examination revealed hypertelorism, low hairline, short neck, and thoracic kyphoscoliosis. Bony crepitus with neck movement was also noted. Radiographic examination revealed scoliosis of thoracolumbar spine with decreased vertebral body height. Poor ossification of odontoid process and atlantoaxial subluxation were also noted (Fig. 1). General anesthesia was induced with 55 mg of thiopental. After demonstrating that the lungs could be easily ventilated by bag and mask without neck extension or flexion, 25 mg of succinylcholine was given to facilitate endotracheal (ET) intubation. A specially designed pediatric lightwand (Trachlight; Laerdal Medical Corporation, Wappingers Falls, NY, USA) encased in a lubricated uncuffed ET tube (Kendall, ID: 5.0 mm) with the lighting tip protruding just beyond the bevel of the ET tube was inserted (Fig. 2). After the location of the light bulb was confirmed in the trachea, the ET tube was threaded gently into the trachea. During the whole intubation process, there was no neck movement. Intraoperative course was uneventful, and the patient was extubated while he was still deeply anesthetized and he recovered from anesthesia smoothly. He was discharged on the next day. 3. Discussion
* Corresponding author. Department of Anesthesiology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan, R.O.C. E-mail: [email protected] (S.-Z. Fan). y There is no conflict of interest. z Support was provided solely from institutional and/or departmental sources.
Lightwand intubation technique needs less manipulation of C-spine movement in sharp contrast to direct laryngoscopy3 and has been used successfully in adult patients with cervical spine injury.4 Although lightwand intubation procedure is considered
1875-4597/$ e see front matter Copyright Ó 2011, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.aat.2011.05.003
Modified lightwand intubation of children
67
Fig. 1. Cervical spine X-ray, lateral view. Left film shows decreased vertebral body height and short neck. Right film shows atlantoaxial subluxation (arrow).
a safe and effective alternative way for tracheal intubation in pediatric patients,5 there is limited information to date about managing unstable cervical spine in infants or children with the lightwand intubation technique. In enclosing the light stylet in the ET, it is suggested that the tip of the stylet is anchored just inside the tracheal tube.6 Usually, in the adult patients, the glottic opening is much bigger than the outer diameter of the ET tube used. In pediatric patients, the reasons for the failure of lightwand intubation (inappropriately large ET tube, truly difficult tracheal entry, or other technical problems) are difficult to differentiate.7 To remedy these ambiguous drawbacks in lightwand intubation usage in complicated situations, we modify the lightwand intubation procedure. We bend the pediatric light wand, which is enclosed in the lubricated ET approximately to 80 in “hockey-stick” formation. The bend takes approximately at the base of the tongue along the patient’s profile such that the stylet tip is at the level of the
Fig. 2. Photograph of modified lightwand endotracheal (ET) tube assembly. The pediatric wand (Trachlight) was bent to around 80 “hockey-stick” formation. The bend was made at approximately the base of the tongue along the patient’s profile, such that the stylet tip was at the level of the laryngeal inlet when the proximal portion was situated in the oropharynx. An uncuffed tracheal tube (of diameter selected on the basis of the patient’s age) was then mounted on the pediatric lightwand with the tip of the light stylet protruding beyond the ET tube. The wand light tip was left naked by placing the ET tube just below the bending site (arrow).
laryngeal inlet when the proximal portion is situated in the oropharynx.8 The lighting tip of the wand is left to protrude the ET tube just below the bending site. The assembled lightwand is inserted so that the naked tip of the light stylet is made to enter the trachea first and then the ET tube is gently threaded into the trachea. Entry into the glottic opening in pediatric patients is much easier using a naked wand tip alone than a conventional tube wand assembly. Once the light stylet transilluminates the trachea at proper position, we have overcome the difficulty of trachea entry. Failed intubation because of an oversized ET tube can be easily detected by the unusual resistance encountered when threading the ET tube. This maneuver can also reduce trauma to the glottic structure caused by repeated trials. Our modified lightwand intubation procedure can give both visual and tactile confirmation of the proper tube size and position. In clinical studies, there is no evidence of burn injuries caused by conventional use of Trachlight. As for our modification, the risk of tracheal mucosal burn caused by modified lightwand intubation procedure could be very low. The reasons are as follows. Modified lightwand intubation can mostly be completed in less than 30 seconds, following the first blink of Trachlight. Animal study has also demonstrated that the trachea mucosa is not injured even by a 250-second focused Trachlight tip exposure.9 In clinical practice, the tip of the lightwand is on moving rather than fixed stationarily at a single location on the tracheal mucosa. Further investigation about safety and efficacy will be done in the near future. There are few previous reports on the anesthetic management of SDC.10e12 Although successful tracheal intubation by direct laryngosopy has been reported,12 Redl13 reported the case of a young patient with SDC in whom massive pyramidal tract signs developed after direct laryngoscopic tracheal intubation, resulting in mortality. In our case, the anticipated difficult airway and possibly unstable cervical spine was successfully managed by using modified lightwand intubation without neck movement. In surgically treated children with dwarfism and unstable cervical spine, the objective of airway management is to prevent neck movement. The safest way to approach this objective, as considered, is to have the patient intubated fiberotically under deep general anesthesia facilitated by maintaining ventilation and anesthesia first with a nasopharyngeal airway. However, fiberoptic intubation requires expensive equipment and a high level of skill.
68
In conclusion, we successfully intubated a child with SDC with difficult airway and unstable cervical spine by a modified lightwand intubation procedure. When managing pediatric patients with possibly unstable cervical spine, such as trauma victims, rheumatoid arthritis, Down’s syndrome, and so on, the use of modified lightwand intubation should be considered as a safer intubation alternative than direct laryngoscopy. References 1. Miyoshi K, Nakamura K, Haga N, Mikami Y. Surgical treatment for atlantoaxial subluxation with myelopathy in spondyloepiphyseal dysplasia congenita. Spine (Phila Pa 1976) 2004;29:E488e91. 2. Xue FS, Yang QY, Liao X, He N, Liu HP. Lightwand guided intubation in paediatric patients with a known difficult airway: a report of four cases. Anaesthesia 2008;63:520e5. 3. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005;101:910e5. 4. Weis Jr FR. Light-wand intubation for cervical spine injuries. Anesth Analg 1992;74:622.
C.-P. Lin et al 5. Holzman RS, Nargozian CD, Florence FB. Lightwand intubation in children with abnormal upper airways. Anesthesiology 1988;69:784e7. 6. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg 2000;90:745e56. 7. Fisher QA, Tunkel DE. Lightwand intubation of infants and children. J Clin Anesth 1997;9:275e9. 8. Chen TH, Tsai SK, Lin CJ, Lu CW, Tsai TP, Sun WZ. Does the suggested lightwand bent length fit every patient? The relation between bent length and patient’s thyroid prominence-to-mandibular angle distance. Anesthesiology 2003;98: 1070e6. 9. Nishiyama T, Matsukawa T, Hanaoka K. Safety of a new lightwand device (Trachlight): temperature and histopathological study. Anesth Analg 1998;87: 717e8. 10. Tofield CE, Mackinnon CA. Cleft palate repair in spondyloepiphyseal dysplasia congenita: minimizing the risk of cervical cord compression. Cleft Palate Craniofac J 2003;40:629e31. 11. de Boer HD, Hemelaar A, van Dongen R, Gielen MJ. Successful epidural anaesthesia for Caesarean section in a patient with spondyloepiphyseal dysplasia. Br J Anaesth 2001;86:133e4. 12. Mogera C, Muralidhar V. Spondyloepiphyseal dysplasia congenita syndrome: anesthetic implications. Anesth Analg 1996;83:433e4. 13. Redl G. Massive pyramidal tract signs after endotracheal intubation: a case report of spondyloepiphyseal dysplasia congenita. Anesthesiology 1998;89: 1262e4.