Airway Management of Severe Subglottic Stenosis with a Novel Airway Device

Abstract

S

ubglottic stenosis (SS) is the leading cause of stridor in pediatric age group. It involves narrowing of subglottic lumen due to incomplete recanalization during embryogenesis (congenital) or after trauma (post intubation). Stridor is the important symptom of SS and usually present in both phases of respiration. Airway management becomes a challenging task to the anesthesiologist in SS due to difficulty in maneuvering endotracheal tube (ETT) through the noncompliant stricture. Location and extent of stricture also pose difficulty in securing front of neck access [1].

 After taking consent of the child’s parent for possible publication in a medical journal, we present a case of subglottic stenosis posted for emergency tracheostomy and ventilated with a novel airway device prepared by simple equipments present in operation theatre.

Case Report

A one-year-old baby of 11 kg presented to the emergency with chief complaint of noisy breathing developed after upper respiratory tract infection (URTI), fever and cough since 2 days. Child’s stridor started since birth that was progressive in severity and frequency, aggravated by recurrent URTI.

At the time of admission, child was in severe respiratory distress with intercostals and suprasternal retraction. Nasal flaring was present with weak cry. Bilateral air entry was decreased with harsh bronchial sounds on auscultation. Hemodynamically child was unstable with heart rate 200 per minute, blood pressure 60/36 mmHg, respiratory rate 44 per minute, axillary temperature 38.5 degree Celsius and SpO2 62% at room air and 88% with Oxygen given by facemask and reservoir at 10 liters per minute. ABG showed pH 7.32, PO2 52 mm Hg, PCO2 68 mm Hg, HCO3 20.2 meq/l and Hb 10.6 mg/dl. Emergency CECT was done which showed the subglottic stenosis of 2.6 mm in length and 2.0 mm of patent airway in diameter at the narrowest point [Figure 1].

Securing the airway was planned with endotracheal intubation followed by surgical tracheostomy and definite correction. Tracheostomy could be done under sedation in a spontaneously breathing child with the aid of facemask or supraglottic airway device. However, an unsuccessful attempt in tracheostomy could completely obstruct the airway and patient may suffer hypoxia.

ETT of 2.0 mm ID was not available that day so we decided to make a novel device in place of ETT. We developed a novel airway device by using 6F suction catheter (SC), 18 G intravenous needle catheter, 3.5 mm ID Endotracheal tube connector and guide wire of 10 F Foleys catheter. We cut the connecting end of SC to resize it equivalent to the length of 2.5mm ID ETT and marking the SC with marker at 6 to 10 cm, 1 cm apart. Foleys guide wire was inserted in the SC and whole