Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome

The ideal airway management modality in pediatric patients with syndromes like Klippel- Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity [wherein the scapulae ride high on the back], synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fi beroptic intubation through classic laryngeal mask airway [LMA]. After intubation, we used second smaller endotracheal tube [ETT] to stabilize and elongate the first ETT while removing the LMA

Comparison of ease of intubation in right and left lateral position using C-MAC videolaryngoscope

Endotracheal intubation is conventionally performed in the supine position. It may sometimes be required to secure the airway in the lateral position, but in lateral position intubation is usually considered to be difficult because the laryngeal view is often compromised. Also anesthesiologists are not used to intubation in lateral position. There can be many methods of securing airway in lateral position besides with the aid of direct laryngoscopy, e.g. through laryngeal mask airway or intubating LMA, or with the use of light wand or a video laryngoscope. C-MAC video laryngoscope, a newer device using a modified Macintosh blade, may be useful in intubation in lateral position. To compare ease of intubation in right and left lateral position using C-MAC video laryngoscope. Study was conducted in KLE, Dr Prabhakar Kore Charitable Hospital. 100 patients with ASA grade I and II, randomly allocated to either Group I [right lateral position] or Group II [left lateral position]. Patients with predicted difficult airways were excluded. After induction of anesthesia, the patient was put in lateral position and intubation was done by a consultant anesthesiologist who is well-versed in using C-MAC laryngoscope. Time for intubation, number of attempts, modified Cormack-Lehane grade, mucosal injury, and need of external laryngeal manipulation were noted. Overall intubation success rate was 100%. The time taken in right lateral group was 25.8 +/- 9.5 seconds and in left lateral group was 26.8 +/- 5.5 seconds; the difference being statistically not significant. The number of intubation attempts was not significant. Cormack-Lehane grade was comparable. Mucosal injury and use of external laryngeal manipulation was more in right lateral group. Intubation can be done in right or left lateral position with similar success and ease. C-MAC video laryngoscope thus seems to be an effective approach for emergently securing airway in patients positioned laterally