An easy technique to maintain depth of inhalational anesthesia under spontaneous respiration without specialized facemasks during pediatric fiberoptic intubation

Sir, A 4-year-old male child with posttraumatic temperomandibular joint ankylosis was posted for ankylosis release. On examination, mouth opening was 2 mm with normal neck extension. Systemic examinations and blood investigations were normal. Plan of anesthesia was inhalation induction followed by fiberoptic intubation maintaining spontaneous respiration. He was induced with sevoflurane 8% in oxygen using a Jackson-Rees circuit, and intravenous access was established. Glycopyrrolate 0.05 mg was given intravenously. Both the nostrils were decongested with oxymetazoline drops. A soft well-lubricated nasopharyngeal airway (22 FG) after attaching a connector of a 4.0-mm endotracheal tube to its proximal end (Fig. 1a) was introduced through the left nostril. Jackson-Rees circuit was then attached to the airway, and anesthesia was continued with sevoflurane 8% in oxygen at a flow rate of 4 l/min. Neck extension was given, and adequate bag movements and regular end-tidal carbon dioxide waveforms were observed.Figure 1: (a) Nasopharyngeal airway with ETT connector attached to its proximal end, (b) FOB being done through opposite nostril. ETT, endotracheal tube; FOB, fiberoptic bronchoscope.Then, through the opposite nostril, a pediatric bronchoscope preloaded with a 5.0 mm nasal Ring-Adair-Elwyn tube was passed (Fig. 1b) up to carina and endotracheal tube was railroaded. After ensuring regular end-tidal carbon dioxide waveforms and bilateral air entry on auscultation, fentanyl 30 mcg, ketamine 15 mg, and atracurium 7.5 mg were given intravenously. Intraoperative period was uneventful. Surgery lasted for 3 h, and the child was extubated when fully awake after reversing neuromuscular blockade. Awake fiberoptic intubation is the gold standard for securing airway whenever a difficult airway with restricted mouth opening is encountered [1,2]. This may be possible with adult cooperative patients but not in pediatric population. Inhalation induction maintaining spontaneous breathing is considered safe rather than intravenous agents while dealing with difficult airway as emergence from inhalation induction is quicker in case airway adverse events are encountered. Compared with adult fiberoptic intubation, pediatric intubations are technically difficult and time consuming [3]. The common problem encountered during pediatric fiberoptic intubation is lighter plane of anesthesia with a higher risk of laryngospasm as face mask has to be removed during the procedure. Use of an endoscopy mask with a self-sealing diaphragm for introduction of fiberoptic bronchoscope could solve this problem [3,4]. However, the mask itself or adequate sizes may not be available always. Although dexmedetomidine could be tried maintaining spontaneous breathing [5], the risk of unintentional apnea cannot be ruled out. With the technique we described, depth of inhalational anesthesia can be maintained throughout the procedure. Care should be taken to use a proper-sized, soft nasopharyngeal airway after nasal decongestion to minimize the risk of trauma. Neck extension during procedure helps to reduce airway obstruction. In patients with sufficient mouth opening, pulling out the tongue with Magill’s forceps helps to prevent tongue from falling back, obstructing and obscuring airway visibility during fiberoptic bronchoscope. As anesthetic gases can leak out through the mouth, use of higher gas flows with higher concentration of inhalational agent may be required. It can be concluded that during pediatric fiberoptic intubation, the depth of inhalational anesthesia can be maintained through a nasopharyngeal airway introduced through the opposite nostril in the non-availability of specialized facemasks meant to be used in such circumstances. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.