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Management of Difficult Airway in Cleft Palate Surgery with Laryngomalacia

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:

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Management of Difficult Airway in Cleft Palate Surgery with Laryngomalacia

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  1. Management of Difficult Airway in Cleft Palate Surgery with Laryngomalacia Presented by: Sc 陳鴻仁 鄭媚方 林綺英

  2. 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)

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

  4. 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

  5. Congenital Anomalies • Cleft Palate • Laryngomalacia, laryngeal web (ant) • Right inguinal hernia • Spinal bifida

  6. 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

  7. Bronchoscopy 麻醉紀錄 • 90/03/27

  8. 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

  9. Anesthesia Record (91/02/22)

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. Anaesthetic Implications (X) Postoperative Care: • With increasing obstruction: • Racemic epinephrine inhalations → no improvement after 2 tx: endotracheal reintubation • Corticosteriods alone • Combination of both

  24. 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

  25. 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

  26. 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

  27. Management of Airway Obstruction

  28. 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

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