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• W4387166677 abstract "Sir, In pediatric patients, there is always a risk of hypoxemia during the management of difficult airways. Fiberoptic intubation is the gold standard for difficult airway management.[1] Many places do not have pediatric-sized fiberscopes, and in this case series of four patients, we describe a method to intubate a child using a fiberscope of greater size than the tube with the help of I-gel and a bougie. In the first case a 2-year-old, 11 kg, male child with huge hydrocephalus was posted for a ventriculoperitoneal shunt. He was induced using intravenous fentanyl 2 μgm/kg, propofol 20 mg, and atracurium 10 mg was given after confirmation of adequate mask ventilation. Laryngoscopy was attempted, but the epiglottis could not be visualized. I-gel size 2 was introduced to ensure proper ventilation. We did not have a pediatric fiberscope but had a rhino laryngoscope with an outer diameter of 3.7 mm, which was inserted through I-gel size 2 and vocal cords with a Brimacombe score of 3 were seen. A pediatric bougie was then introduced by the side of this rhino laryngoscope in the I-gel and under vision negotiated inside the trachea [Figure 1]. The fiberscope was then removed to create room for the tube. An uncuffed endotracheal tube size 4 mm was then railroaded on this bougie while still inside the I-gel. The bougie was removed and correct tracheal tube placement was confirmed by end tidal carbon dioxide. The I-gel was then removed. The second case was a 7-month-old male posted for excision of a large right-neck lymphovenous malformation. A 3.5 mm uncuffed tube was placed in the manner as described above. Two 3-year-old children, who were both operated cases of temporomandibular joint ankylosis, were posted for implant removal. Size 4 mm cuffed tube could be placed through the I-gel size in both cases.Figure 1: Showing bougie inserted from the side of a rhino laryngoscopeThis case series highlights how we were able to effectively overcome the challenge of intubating a child with a difficult airway using a greater diameter bronchoscope and smaller-sized endotracheal tube using a supraglottic device and a bougie. The authors have performed endotracheal intubation with the help of I-gel in very difficult airways in a child with Morquio’s syndrome or managed children with Pierre Robin syndrome in acute respiratory distress.[2,3] Rhino laryngoscope is a flexible videoendoscope used by otolaryngologists for examination of the nose, throat, and airway. The authors have used the nasopharyngoscope in airway management of palatoglossal band in children.[4] Traditional teaching dictates that all supraglottic device-aided intubations should be guided real-time by a fiberscope.[5] Through this manuscript, we wish to highlight that using our technique, even in resource-limited places, intubations with a small-sized tube may be performed safely under direct vision with rhino laryngoscope with the help of I-gel and a bougie even if the glottis view has a Brimacombe score of 3 with a fiberscope. We feel it can easily be used as a standard method in tricky intubations if the mouth opening is large enough to accommodate an I-gel. There was no episode of hypoxuia in any of the cases and we found this method safe. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4387166677 date "2023-01-01" @default.
• W4387166677 modified "2023-09-30" @default.
• W4387166677 title "Rhino- laryngoscope assisted bougie insertion through I-gel for endotracheal intubation in a child with an anticipated difficult airway" @default.
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• W4387166677 doi "https://doi.org/10.4103/joacp.joacp_400_21" @default.
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