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Fiberoptic Endotracheal Intubation After Topicalizationwith In-Circuit Nebulized Lidocaine in a Child with aDifficult Airway Ban C. H. Tsui, MD, MSc, FRCP(C), and Kirsten Cunningham, MB ChB *Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada This case report describes the successful fiberoptic intuba- circle system via a T-piece adapter. This case suggests that tion of an uncooperative child with a difficult airway due simultaneously administering a volatile anesthetic with to gross burn scarring in the facial and neck region by ad- nebulized lidocaine might be an alternative way to deliver ministering 4% end-tidal sevoflurane and simultaneously lidocaine and might provide better topical anesthesia for delivering 4% nebulized lidocaine via a small-volume nebulizer that was connected to the inspiratory limb of the (Anesth Analg 2004;98:1286–8) Difficult airways in pediatric anesthesia may be area during a gas explosion. In addition, this patient had managed by using inhaled induction followed chromosome 9p duplication syndrome, which is associated by the topical application of local anesthesia to with global developmental delay, mental retardation, andcharacteristic craniofacial and skeletal malformations. The the airway in spontaneously breathing patients. This patient also had a history of difficult airway management. A technique requires precise timing and an appropriate laryngeal mask (LMA) was required for a previous opera- depth of anesthesia, because stimulation of the airway tion immediately after inhaled induction because the patient in a child who is only lightly anesthetized increases became apneic and did not maintain a patent airway with the potential for desaturation and hypoxemia due to positive mask ventilation. After multiple failed intubation coughing and laryngospasm. Waiting too long before attempts by direct laryngoscopy, fiberoptic intubation via manipulation of the airway could increase the partial LMA was successful.
The physical examination revealed a frightened and badly pressure of the volatile anesthetic in the body and scarred boy weighing 20 kg, with severe contractures in the result in apnea and bradycardia. This report describes face and neck region. There was an obvious limitation of the successful fiberoptic intubation of an uncoopera- mouth opening and a deformity of the neck, which was tive child after the airway was anesthetized with 4% characteristically short with virtually no flexion or exten- nebulized lidocaine and simultaneous administration sion. His nostrils were also not patent.
of a volatile anesthetic.
The anesthetic plan was to attempt fiberoptic intubation after inhaled induction with sevoflurane. In the event thatthe airway became lost, our plan was to secure the airway with an LMA, which had been successful in the past. Tra-cheostomy was also considered if there was any compro- An 8-yr-old boy was scheduled for a repeated operation of mise of patient safety. Equipment for this was kept ready in scar releasing and skin grafting of the nasal, facial, and neck the operating room.
region (Fig. 1). Two years previously, the patient had sus- Anesthetic induction was performed with 8% sevoflurane tained a burn involving 65%–70% of his total body-surface with 100% oxygen. Transient apnea occurred but quicklyresolved by reduction of sevoflurane to 4% end-tidal. Thepatient was maintained with 4% end-tidal sevoflurane. A Supported in part by the Education and Research Fund, Department 22-gauge IV line was established, and the patient received IV of Anesthesiology and Pain Medicine, University of Alberta Hospitals, glycopyrrolate 0.01 mg/kg. After 5 min, an adequate depth Edmonton, Alberta, Canada; and the Clinical Investigatorship Award, of anesthesia was reached, and the nebulization of 4% lido- Alberta Heritage Foundation for Medical Research, Alberta, Canada.
caine with auxiliary oxygen at a flow rate of 4 L/min was Accepted for publication November 4, 2003.
Address correspondence and reprint requests to Ban C. H. Tsui, initiated (Fig. 2). The nebulization was discontinued after MD, MSc, FRCP(C), Department of Anesthesiology and Pain Med- exactly 5 min, and fiberoptic intubation was then performed.
icine, University of Alberta Hospitals, 3B2.32 Walter Mackenzie The child tolerated the procedure well, without coughing or Health Science Centre, 8440-112 St., Edmonton, Alberta, Canada desaturating, while breathing spontaneously. After intuba- T6G 2B7. Address e-mail to btsui@ualberta.ca.
tion, the endotracheal tube was wired to the front tooth. The patient was stable throughout the 3-h operation and was 2004 by the International Anesthesia Research Society Anesth Analg 2004;98:1286–8




2004;98:1286 –8 were performed after topicalization with in-circuitnebulized lidocaine. Upper airway manipulations,such as awake fiberoptic intubation, are often poorlytolerated in pediatric patients. Local and regional an-esthesia techniques are frequently used to reduce theirritation associated with these procedures. Thesetechniques are readily performed in awake or sedatedadults but may require general anesthesia in children.
It is prudent to maintain spontaneous respiration in ananesthetized child with a compromised airway. In-haled induction in a child with a difficult airway ischallenging, and the risks of airway obstruction, la-ryngospasm, and airway compromise are everpresent, especially with premature intervention. Deepanesthesia under these circumstances may cause ap-nea and cardiovascular depression. Although the top-ical application of local anesthetics by using nebuliza- Figure 1. The endotracheal tube was wired to the front tooth of an
8-yr-old boy with burn scar contractures of the nasal, facial, and
tion is one of the least invasive methods of neck region.
anesthetizing the airway in awake adults, this ap-proach may be difficult to effectively administer touncooperative children.
In this case, the child had chromosome 9p duplica- tion syndrome, which is characterized by mental re-tardation and craniofacial abnormalities. In addition,the patient had a limited range of mouth opening andneck motion because of scarring from a previous burn.
Securing the airway in an uncooperative pediatric pa-tient with severe facial and neck burns is a challenge,even to the most experienced anesthesiologist. Thechosen anesthetic technique was influenced by previ-ous failed attempts to secure a patent airway in thepatient by direct laryngoscopy. Although the patient'sairway was previously obtained with fiberoptic en-doscopy via an LMA, in our opinion the potential fora life-threatening situation might be minimized in thisparticular patient by fiberoptic intubation under spon-taneous respiration.
Figure 2. In-circuit nebulized lidocaine setup. A small-volume neb-
Nebulizing airways with local anesthetics through a ulizer was connected to the inspiratory limb of the circle system viaa T-piece adapter.
small-volume nebulizer is routinely used in adults forairway management. However, we anticipated thatthis method would be time consuming and poorly tracheally extubated fully awake without difficulty at the tolerated in this unsedated patient. We hypothesized end of the procedure.
that simultaneously administering a volatile anes- One week later, the patient was rescheduled for another elective skin grafting. Anesthesia was successfully induced thetic with nebulized lidocaine would more effectively with 4% sevoflurane without apnea or desaturation. Again deliver lidocaine and provide better topical anesthesia the patient received 5 min of nebulized 4% lidocaine with for an uncooperative patient. With this technique, the 4% end-tidal sevoflurane. Fiberoptic intubation was easily patient was able to tolerate fiberoptic intubation while performed, and the child tolerated the procedure well, with- spontaneously breathing. IV lidocaine after sevoflu- out coughing or desaturation. The patient was tracheally rane induction has been shown to decease coughing extubated at the end of surgery without complications and and attenuate blood pressure increases after tracheal was discharged home 7 days later.
intubation in children (1,2). Other combinations, suchas propofol and sevoflurane, have been reported todecrease minimum alveolar anesthetic concentration requirements for intubation, but they may increase the This is the first described case of a difficult airway in risk of apnea (3). Convulsions from local anesthetic a child with gross burn scarring in the facial and neck toxicity have been reported from the nebulization of region in whom two successful fiberoptic intubations lidocaine (4,5).


2004;98:1286 –8 We recently conducted an in vitro study to evaluate the rate at which lidocaine is nebulized from small- 1. Jakobsen CJ, Ahlburg P, Holdgard HO, et al. Comparison of volume nebulizers at different oxygen flow rates (6).
intravenous and topical lidocaine as a suppressant of coughing Approximately 0.2 mL/min of 4% lidocaine is nebu- after bronchoscopy during general anesthesia. Acta Anaesthesiol lized when the dispersing oxygen flow rate is 4 Scand 1991;35:238 – 41.
L/min. This 4 L/min flow from the auxiliary oxygen, 2. Sayyid SS, Zalaket MI, Baraka AS. Intravenous lidocaine as ad- combined with a 4 L/min flow of oxygen and 8% juvant to sevoflurane anesthesia for endotracheal intubation inchildren. Anesth Analg 2003;96:1325–7.
sevoflurane from the anesthesia machine, results in an 3. Satsumae T, Watanabe S, Yamaguchi H. The effect of propofol 8 L/min total gas flow with a 4% concentration of infusion on minimum alveolar concentration of sevoflurane for sevoflurane. During a 5-minute exposure to lidocaine smooth tracheal intubation. J Anesth 2002;16:28 –33.
nebulized in this fashion, the child would have re- 4. Groeben H, Schlicht M, Stieglitz S, et al. Both local anesthetics ceived a maximum of 40 mg of lidocaine (1 mL of 4% and salbutamol pretreatment affect reflex bronchoconstriction involunteers with asthma undergoing awake fiberoptic intubation.
lidocaine), which is much less than the maximum recommended dose of IV or nebulized lidocaine for 5. Efthimiou J, Higgenbottam T, Holt T, et al. Plasma concentrations any child weighing more than 10 kg (i.e., ⬍4 mg/kg of lignocaine during fibreoptic bronchoscopy. Thorax 1982;27: lidocaine) (7).
6. Tsui BCH, Malherbe S. Nebulization of lidocaine with varied Although this technique may facilitate fiberoptic- oxygen flow rates. Anesth Analg 2003;97:302.
assisted intubation in anesthetized, spontaneously 7. Gjonaj ST, Lowenthal DB, Dozor AJ. Nebulized lidocaine admin- breathing children with compromised airways, fur- istered to infants and children undergoing flexible bronchoscopy.
ther studies are warranted to determine the feasibility and efficacy of using an in-circuit nebulization systemto deliver specific medications.

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