Case report
Endotracheal intubation through laryngeal Ambu® Auragain™ mask airway mask in paediatric patients affected by congenital infiltrating lipomatosis
Intubación orotraqueal a través de mascarilla laríngea Ambu® Auragain™ en paciente pediátrico con lipomatosis infiltrante congénita
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Hernández García, I. Hidalgo, L. Barragán, B. Berenguer, C. Lorca-García, I. Mantilla" "autores" => array:6 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Hernández García" "email" => array:1 [ 0 => "inmaculada.hernandez0@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Hidalgo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Barragán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "B." 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"apellidos" => "Mantilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía Plástica Infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intubación orotraqueal a través de mascarilla laríngea Ambu<span class="elsevierStyleSup">®</span> Auragain™ en paciente pediátrico con lipomatosis infiltrante congénita" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 669 "Ancho" => 905 "Tamanyo" => 93300 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intubation material, consisting of fibreoptic bronchoscope, number 2 Ambu<span class="elsevierStyleSup">®</span> Auragain™ laryngeal mask, number 4.5 endotracheal tube, number 4 endotracheal tube without connection, swivel adapter, guedel cannula.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital infiltrating lipomatosis of the face is a type of lipomatous tumour that begins in the early years of development. It is well defined clinically as being characterized by diffuse fatty infiltration of the facial soft tissues, such as striated muscle tissue. It is a fast-growing tumour, associated with bone hyperplasia, especially in the maxilla and mandible, with a high incidence of recurrence after surgical treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Congenital malformations involving the airway can cause problems with ventilation, intubation, or even both, resulting in an increased risk of hypoxaemia.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Concerns about complications arising from poor management of the paediatric airway have been growing, since the main causes of morbidity, mortality and cardiorespiratory arrest in this population are related to respiratory problems and airway control.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The paediatric airway differs from that of adults in terms of size, shape and position, and correct management is particularly important in patients with malformations that affect the head, neck or cervical spine. The latest supraglottic devices, such as the air-Q (air-Q, Mercury Medical, Clearwater, FL, USA) and the Ambu<span class="elsevierStyleSup">®</span> Auragain LMA have been modified in recent years to improve airway management in both adults and children.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with congenital infiltrating lipomatosis with face and neck involvement and anticipated difficult airway who was scheduled for liposuction of the lesion, and describe the specific management of this case.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a male patient aged 3 years and 1 month, weight 13<span class="elsevierStyleHsp" style=""></span>kg and height 96<span class="elsevierStyleHsp" style=""></span>cm, ASA I, scheduled for surgery by the Paediatric Plastic Surgery service for soft tissue reduction, liposuction and correction of right-sided ectropion. The patient had no other personal history of interest: controlled pregnancy, term eutocic delivery (gestational age 38 weeks), and adequate weight for gestational age (3100<span class="elsevierStyleHsp" style=""></span>g). He presented congenital infiltrating lipomatosis with progressive evolution that did not cause functional alterations in swallowing, respiration or phonation. Weight-to-height ratio and psychomotor development were appropriate for his age.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After obtaining signed informed consent from his legal guardians, the airway was examined during the pre-anaesthesia evaluation. The findings included: important facial deformity with deviation of naso-buccal structures to the contralateral side, Mallampati grade III with deviated buccal opening, macroglossia, and normal neck mobility. In a previous surgery performed in another hospital, he had been intubated with a fibreoptic bronchoscope.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The airway approach was planned by consensus decision of several paediatric anaesthesiologists, and was based on current paediatric difficult intubation guidelines.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> After evaluating different strategies, and ruling out awake intubation due to the lack of patient collaboration, intubation through a number 2 Ambu<span class="elsevierStyleSup">®</span> Auragain™ LMA after inhalational induction with spontaneous breathing was decided.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was premedicated with oral midazolam 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg 30<span class="elsevierStyleHsp" style=""></span>min before surgery. Monitoring consisted of pulse oximetry, non-invasive blood pressure, ECG, capnography (exhaled etCO<span class="elsevierStyleInf">2</span>), tidal volume, and respiratory rate. Inhalation induction was performed with sevoflurane at dosage increments of 2%–6%, maintaining spontaneous ventilation. Following this, a 20G peripheral line was placed, and atropine was administered at doses of 0.01<span class="elsevierStyleHsp" style=""></span>mg/kg together with fractional boluses of fentanyl up to a total of 2<span class="elsevierStyleHsp" style=""></span>mcg/kg. After direct diagnostic laryngoscopy, which showed a Cormack-Lehane III grade airway, the number 2 LMA was inserted (Ambu<span class="elsevierStyleSup">®</span> Auragain™), verifying adequate spontaneous ventilation, bilateral auscultation and positive capnography. This was followed by intubation via the laryngeal mask using a cuffed number 4.5 endotracheal tube, ventilating through a swivel adapter mounted on the 2.8<span class="elsevierStyleHsp" style=""></span>mm paediatric fibreoptic bronchoscope, administering 3<span class="elsevierStyleHsp" style=""></span>ml of 1% lidocaine powder through the working channel. The surgical procedure could not be performed with the LMA in place, so it was removed, leaving just the endotracheal tube. To do so, a number 4 diameter tube without connector was inserted to extend the length of the tube and the LMA was extracted by sliding it over the tube (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient maintained spontaneous ventilation and peripheral oxygen saturation greater than 96% throughout the procedure, with adequate pulmonary auscultation. Once the LMA had been removed, we re-checked the endotracheal tube with the fibre-optic bronchoscope to confirm it remained correctly in place. Anaesthesia was maintained with continuous perfusion of 0.1<span class="elsevierStyleHsp" style=""></span>mcg/kg/min sevoflurane and remifentanil, and the patient was extubated after eduction and complete recovery of consciousness. After extubation, he was transferred to the post anaesthesia care unit with pulse oximetry monitoring and supplementary oxygen delivered through a face mask.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The main objective of paediatric airway management is to ensure adequate oxygenation. Routine management in a healthy paediatric patient is usually straightforward for experienced anaesthesiologists, although it can sometimes be challenging for non-paediatric anaesthesiologists. In paediatric patients, ventilation difficulties and the failure of direct laryngoscopy are rare. More than 2 direct laryngoscopy attempts in children is associated with high rates of intubation failure and complications,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> which increase with each intubation attempt. Anaesthesiologists treating paediatric patients should bear in mind that: (a) the number of attempts at direct laryngoscopy must be minimized, and the strategy should be changed (video laryngoscope/fibreoptic bronchoscope) when the direct approach fails; and (b) delivery of oxygen through a supraglottic airway during intubation attempts should be considered, as this will reduce the risk of complications associated with hypoxaemia.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As in any case of anticipated difficult airway, pre-surgery planning is fundamental. In our patient, the characteristics of facial lipomatosis suggested not only difficult intubation, but also potential difficulties during ventilation. For this reason, we directed our efforts at maintaining spontaneous ventilation and ensuring correct oxygenation and delivery of the hypnotic agent through the endotracheal tube, using the swivel adapter on the laryngeal mask.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Advances in the design of intubating laryngeal mask airways, such as the air-Q<span class="elsevierStyleSup">®</span> (Mercury Medical) and Ambu<span class="elsevierStyleSup">®</span> Auragain™, facilitate ventilation in paediatric patients when standard face mask and endotracheal intubation are difficult.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The incidence of difficult airway is lower in paediatric patients than in adults, between 0.25% and 3%<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> compared to an incidence of 1.5%–13% in adults.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Anticipated difficult airway in paediatric patients is related to anatomical anomalies associated or not with a congenital syndrome, and with acquired defects such as traumatism and burns.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most widely studied supraglottic devices for airway rescue in paediatric patients are the classic laryngeal mask airway (cLMA) and the Proseal laryngeal mask (PLM) (Intavent Orthofix, Maidenhead, UK). They can be used as a conduit to guide intubation, but the standard models limit the size of the endotracheal tube, especially cuffed tubes. They are also longer, so removal can lead to accidental extubation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The risk of accidental extubation during removal of the LMA after insertion of the endotracheal tube has been reported in the literature, and different methods have been described to prevent this situation.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The Fastrach<span class="elsevierStyleSup">®</span> intubating LMA has a specific exchanger, but it is not available for patients weighing less than 30<span class="elsevierStyleHsp" style=""></span>kg, with number 3 being the smallest size available to date.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The Ambu<span class="elsevierStyleSup">®</span> Auragain™ LMA improves all these features without limiting the size of the tube in the paediatric patient. Guidelines recommend performing fibreoptic bronchoscope-guided intubation under direct vision whenever possible, as this improves the safety profile and success rate of the technique. The guidelines themselves reflect the increased use of fibreoptic-guided intubation through an LMA in paediatric patients with anticipated difficult airway.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Some studies have reported that intubating LMAs have a higher success rate and faster intubation time compared with a modified laryngeal tube.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> This technique also has the advantage of delivering continuous ventilation while manipulating the airway through the LMA and maintaining deep hypnosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">An appropriate extubation protocol was fundamental in this case with anticipated difficult airway. Our patient was a risk case, according to the extubation guidelines of the UK Difficult Airway Society,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> so we chose to perform the procedure after complete recovery of consciousness. Opioids are known to suppress coughing and minimize cardiovascular alterations during extubation. Therefore, we decided to perform extubation with intravenous infusion of remifentanil at decreasing doses to minimize the incidence of cough and laryngospasm during eduction.</p><p id="par0080" class="elsevierStylePara elsevierViewall">An advantage of the Ambu® Auragain™ LMA, and its new paediatric sizes, is the integrated gastric channel, a cuff that guarantees high sealing pressures, anatomical curvature, wide cuff that facilitates intubation, and depth marks for fibreoptic bronchoscopy. This makes it is one of the supraglottic devices of choice for difficult paediatric airway rescue.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1183075" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1103663" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1183076" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1103664" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-26" "fechaAceptado" => "2018-10-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1103663" "palabras" => array:5 [ 0 => "Difficult intubation" 1 => "Paediatric airway" 2 => "Supraglottic airway device" 3 => "Airway anatomy" 4 => "Congenital syndromes" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1103664" "palabras" => array:5 [ 0 => "Intubación difícil" 1 => "Vía aérea pediátrica" 2 => "Dispositivo supraglótico" 3 => "Anatomía vía aérea" 4 => "Síndromes congénitos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital defects that affect paediatric airway could lead to several difficulties for effective ventilation, intubation, or even both, increasing the risk of hypoxaemia. It is essential for the paediatric anaesthesiologist to have accurate knowledge of the anatomy of patient's airway, as well as judicious preoperative planning. Increasingly, more devices have been designed for the control of difficult airway in the paediatric patient. This case report describes the application of a third-generation laryngeal mask (Ambu<span class="elsevierStyleSup">®</span> Auragain ™) for endotracheal intubation of a child with anticipated difficult airway, secondary to congenital diffuse infiltrating facial lipomatosis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las malformaciones congénitas que afectan a la vía aérea pueden generar problemas para realizar una ventilación efectiva, intubación o incluso ambas, con el consiguiente aumento del riesgo de hipoxemia. Es esencial para el anestesiólogo pediátrico el conocimiento exacto de la anatomía de la vía aérea del paciente, así como una planificación preoperatoria cuidadosa. Cada vez son más los dispositivos diseñados para el control de la vía aérea en el paciente pediátrico. Este caso clínico describe el uso de la mascarilla laríngea de tercera generación (Ambu<span class="elsevierStyleSup">®</span> Auragain™) para la intubación orotraqueal de un paciente pediátrico con vía aérea difícil prevista secundaria a lipomatosis infiltrante congénita en la región facial.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández García I, Hidalgo I, Barragán L, Berenguer B, Lorca-García C, Mantilla I. Intubación orotraqueal a través de mascarilla laríngea Ambu<span class="elsevierStyleSup">®</span> Auragain™ en paciente pediátrico con lipomatosis infiltrante congénita. Rev Esp Anestesiol Reanim. 2019;66:222–225.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 669 "Ancho" => 905 "Tamanyo" => 93300 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intubation material, consisting of fibreoptic bronchoscope, number 2 Ambu<span class="elsevierStyleSup">®</span> Auragain™ laryngeal mask, number 4.5 endotracheal tube, number 4 endotracheal tube without connection, swivel adapter, guedel cannula.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malformaciones congénitas de la vía aérea superior" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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