Management of Difficult Airway in Cleft Palate Surgery with LaryngomalaciaPresented by: Sc 陳鴻仁

鄭媚方 林綺英

Birth History 鬥沙 xx (3989749), 14 m/o boy G3P3, GA:35 wks, BBW:1350gm C/S due to fetal distress (89/12/18) Apgar score 3 → 7 Growth and development:

BW: 5.5 kg, BL: 70 cm, HL: 50 cm (<3 percentile)

Maternal History 40 y/o woman Smoking: 1 pack/day Alcohol: 3 bottle/day Betal nuts(+)

Congenital Anomalies Fetal Alcohol Syndrome

Facial anomalies: Short palpebral fissures Broad flat nasal bridge, short upturned nose, Thin upper lip, flat philtrum, micrognathia

Cardiac defects: only TR Abnormal palmar crease (-)

GER: improved by administration of cisapride

Congenital Anomalies

Cleft Palate Laryngomalacia, laryngeal web (ant) Right inguinal hernia Spinal bifida

Apenic Episodes 89/12/18: General cyanosis after delivery Intubation NCPAP 90/2/4: Dyspnea with retraction NCPAP 90/3/12 ~15, 18~21, 22~25: Respiratory distress with severe retraction NCPAP 90/3/27: ETGA for bronchoscopy

Bronchoscopy 麻醉紀錄 90/03/27

Intubation (91/02/22) Laryngoscope: failed Fiberoptic bronchoscope: failed Light wand: failed Laryngeal mask first fiberoptic bronchoscope assisted intubation with 3.5-sized oral RAE

Anesthesia Record (91/02/22)

AT ICU 91/02/22 15:00pm:

SpO2 dropped to 70~80% without ambu-bagging → 4° ETT was reinserted Respiratory failure may be due to tongue swelling

91/02/25~26: corticosteroids q6h (5pm /11pm/5am/11am), extubate at 02/26, 9 am smoothly

Laryngomalacia (I) Short aryepiglottic folds Omega-shaped epiglottis Collapse of supraglottic larynx during insipration → inspiratory stridor Worse: feeding, supine, crying, URI Lessened by neck extension, prone Associated with GER: prone to aspiration

Laryngomalacia (II) Endoscopy: definite diagnosis Surgical intervention (10%): severe respiratory obstruction, cyanosis, apneic attacks, feeding difficulties, failure to thrive Self-limiting: resolves after 18 months

Isolated Cleft Palate Occurs in ~1/1000 births, mostly♀ Problems faced

Feeding → upright or “preemie” nipples, NG tubes Recurrent otitis Media Phonation Cosmetic

TX: delayed until >1 y/o

Anaesthetic Implications (I) Preoperative Evaluation Pay special attention to the airway

condition and other congenital anomalies

No milk for 6 hrs, no clear fluids for 3 hrs prior to surgery

At least 1 unit of blood is available Congenital heart diseases:

prophylactic antibiotics

Anaesthetic Implications (II)Monitor EKG, SpO2, BP, BT, End-tidal CO2 Continuous auscultation with a

stethoscope

Anaesthetic Implications (III)Induction Warm OP room: ~25℃ Avoid sedative premedication Atropine: IV at induction or by hypodermic injection 15~45 min preop; dose: 0.02 mg/kg Inhalation induction: ex. Sevoflurane

Anaesthetic Implications (IV) *Muscle relaxants:

Cleft palate surgery: could be injected into the tongue muscle if IV access cannot be achieved Laryngomalacia: not preferred if respiratory distress occurs

*Ketamine: relative contraindication in laryngomalacia? *If stridor worsens during induction → close pop-off valves to develop 10 cm H2O PEEP

Anaesthetic Implications (V)Intubation Intubate the spontaneously breathing patient under inhalational anaesthesia Cleft Palate:

Bridge the palatal defect when inserting the laryngoscope or via a gauze-pack Use of specific blade: Robertshaw’s or Oxford infant blades Oral RAE tubes are recommended, un-cuffed

Anaesthetic Implications (VI) Tracheotomy equipments should

also be available However, tracheotomy is not the

1° emergency treatment In the event of airway obstruction

during induction, insertion of a small, rigid bronchoscope through the glottis is preferable

Anaesthetic Implications (VII) Analgesia and↓bleeding: lidocaine 0.5% + epinephrine or topical cocaine / epinephrine, or fentanyl IV in 1.0 μg/kg Pay special attention to the breath sounds and chest compliance during placement and manipulation of the Dingman gag

Anesthetic Management (VIII)Extubation Only done when fully awake to decrease the risk of laryngospasm Reversal of muscle relaxants: neostigmine (0.07 mg/kg) and atropine (0.03 mg/kg) Remove any posterior pharynx throat pack Suction pooled blood and secretion Place in prone or lateral (tonsil) position Arm restraints: from disrupting repair

Anaesthetic Management (IX)Postoperative Care Closely monitored for at least 1st 24 hrs Humidified oxygen Paracetamol suppositories (60~120mg) are helpful in achieving analgesia Narcotic use: morphine 0.025 mg/kg IV, repeat no more than every 10 min, total dose <0.1 mg/kg

Anaesthetic Implications (X)Postoperative Care: With increasing obstruction:

Racemic epinephrine inhalations → no improvement after 2 tx: endotracheal reintubation Corticosteriods alone Combination of both

Anaesthetic Management (XI)Postoperative Care: Babies can be fed 2 hr after operation if recovery is fair Nursed slightly head up to ↓edema formation A fluid or semifluid diet is maintained for 3 wk

Postop Airway Obstruction, Causes? Tongue swelling associated with mouth gag blade→ most common Subglottic edema Flap edema Increased oral secretion Posterior displacement of the tongue An overlooked throat pack

PostOP Airway Obstruction (II) Laryngospasm: due to stimulation of glottic or supraglottic mucosa by irritants → complete airway obstruction

Complications: Vomiting (7%) Bronchospasm (4%) Aspiration (1%) Cardiac arrest (0.5%) Pulmonary edema

Management of Airway Obstruction

References Ashcraft, KW. Pediatric surgery, 3rd ed. Philadelphia : Saunders, c2000 Baxter, M. Congenital laryngomalacia. Can J Anaesth 1994; 41(4): 332~339 Beveridge, M.E. Laryngeal mask anaesthesia for repair of cleft palate. Anaesthesia 1989; 44: 656~657 Dierdorf, SF and Stoelting, R. Anesthesia and co-existing disease, 3rd ed. New York : Churchill Livingstone, 1993 Hodges S.C. Special Article: A protocol for safe anaesthesia for cleft lip and palate surgery in developing countries. Anaesthesia 2000; 55: 436~441 Miller, RD. Anesthesia. New York : Churchill Livingstone, 1990 Morgan, GE and Mikhail MS. Clinical Anesthesiology, 2nd ed. Los Angeles: Prentice-Hall International, Inc., 1996