Awake Bedside Intubation of an Infant Using a Single-Use Flexible Bronchoscope: A Case-Based Technical Report

Flexible bronchoscopic intubation is an established option for the difficult pediatric airway, but its use in small infants without sedation or a supraglottic conduit has not been well described. We report the awake bedside intubation of a 6-week-old female with trisomy 13 and cleft lip and palate presenting with worsening respiratory distress and persistent hypoxemia refractory to high-flow nasal cannula therapy. At the time of intubation, the patient weighed approximately 3.1 kg. Pediatric otolaryngology performed the procedure in the intensive care unit using a single-use Ambu aScope 5 Broncho 2.7/1.2 (2.7-mm outer diameter) preloaded with a 3.5-mm cuffed endotracheal tube, without sedative medications, a supraglottic airway conduit, or adjunctive videolaryngoscopy. Spontaneous ventilation was preserved throughout the procedure. Successful first-attempt tracheal intubation was confirmed with capnography; transient right mainstem positioning required tube withdrawal before radiographic depth confirmation. Flexible tracheobronchoscopy incidentally demonstrated significant tracheomalacia and bilateral bloody secretions. This case demonstrates that awake bedside direct oral intubation using a single-use ultrathin bronchoscope is feasible in small infants with complex craniofacial anatomy and an anticipated difficult airway. Careful monitoring of tube depth during advancement is essential to prevent endobronchial intubation in this population.