Management of Difficult Airway in Cleft Palate Surgery with Laryngomalacia

Presented 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 deliv

ery Intubation NCPAP 90/2/4: Dyspnea with retraction NC

PAP 90/3/12 ~15, 18~21, 22~25: Respirator

y 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 bro

nchoscope 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 (5p

m /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 aspirati

on

Laryngomalacia (II) Endoscopy: definite diagnosis Surgical intervention (10%): severe re

spiratory 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 hypode

rmic 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 patie

nt 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 th

e 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 fo

rmation A fluid or semifluid diet is maintained

for 3 wk

Postop Airway Obstruction, Causes? Tongue swelling associated with mou

th 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, c200

0 Baxter, M. Congenital laryngomalacia. Can J Anaesth 1994; 41(4): 33

2~339 Beveridge, M.E. Laryngeal mask anaesthesia for repair of cleft palat

e. 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 l

ip 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 Ang

eles: Prentice-Hall International, Inc., 1996