Tracheal intubation in a patent with Crouzon's syndrome using LMA-Fastrach[TM] with the Cook Airway Exchange Catheter[R].
Article Type: Case study
Subject: Catheters (Usage)
Craniofacial dysostosis (Risk factors)
Craniofacial dysostosis (Diagnosis)
Craniofacial dysostosis (Care and treatment)
Craniofacial dysostosis (Case studies)
Trachea (Intubation)
Trachea (Health aspects)
Authors: Kim, Y.H.
Kim, H.
Pub Date: 01/01/2009
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: Jan, 2009 Source Volume: 37 Source Issue: 1
Geographic: Geographic Scope: South Korea Geographic Code: 9SOUT South Korea
Accession Number: 193793200
Full Text: We present a case of tracheal intubation through LMA-Fastrach[TM] using Cook Airway Exchange Catheter[R] (CAEC) in a young patient with Crouzon's syndrome.

An 11-year-old male patient with Crouzons's syndrome was scheduled to undergo adenotonsillectomy under general anaesthesia due to obstructive sleep apnoea syndrome. The patient weighed 40 kg and height was 134 cm, respectively. The patient had received Le Fort III osteotomy midfacial advancement surgery seven years before. The difficulty of airway management during his past surgery was unclear. Routine laboratory tests, cardiac echocardiography, electrocardiogram tests were all within normal limits. The patient had the typical appearance of Crouzons's syndrome (large brachycephalic head, prognathism, crowding of the teeth and exorbitism).

During physical examination, several findings, such as limitation of cervical mobility, Mallampati class III-IV airway, mild trismus and a high-arched palate were found, showing a high possibility of a difficult airway. Premedication was injected intramuscularly with 0.08 mg glycopyrrolate and 1 mg midazolam 30 minutes prior to surgery. On arrival at the operation room, it was impossible to gain the patient's cooperation. After attaching standard monitoring, preoxygenation was performed with 100% oxygen for three minutes. A fibreoptic bronchoscope was not available. Anaesthetic induction was performed with intravenous injection of profofol 80 mg, remifentanil 50 [micro]g and rocuronium 30 mg. The boy developed partial respiratory obstruction in spite of the mask being held with both hands and lifting the angle of the mandible. An attempt to introduce oropharyngeal airway resulted in a worsening of obstruction. Direct laryngoscopy was attempted, though it only revealed the tip of the epiglottis (Cormack and Lehane grade 3). The oxygen saturation dropped to 90%. After confirming that the patient's head was properly supported (a silicone donut, 4 cm height) and his head and neck were in a neutral posture, a size 3 LMA-Fastrach[TM] (ILMA Fastrach[TM], Laryngeal Mask Company Ltd, Henley on Thames, UK) was inserted and the cuff inflated. Manual ventilation was adequate and capnography displayed normal endtidal C[O.sub.2] waves. The oxygen saturation was increased to 99%. After optimising ventilation, we used the metal handle to slightly lift the LMA-Fastrach[TM] away from the posterior pharyngeal wall, the second step of the Chandy manoeuvre, before attempting blind tracheal intubation. However, a lubricated size 6 armoured tracheal tube (Wire-Reinforced Endotracheal Tube, Usin Med, Seoul, Korea) could not be easily inserted. A second attempt with size 5.5 armoured tracheal tube was made after repositioning the LMA-Fastrach[TM] by Chandy manoeuvre. Despite these two attempts, tactile resistance was repeatedly encountered and tracheal intubation was unsuccessful.

Manual lung ventilation was performed between each attempt with 100% oxygen and 2 vol% sevoflurane and oxygen saturation was maintained above 99%.

A lubricated CAEC (Cook Critical Care, Bloomington, IN, USA) was used in order to achieve successful tracheal intubation. The lubricated 3 mm CAEC was inserted through LMA-Fastrach[TM]. The catheter was connected to the anaesthetic circuit by a a Rapi-Fit Adapter. Although there was severe resistance during manual bag-ventilation, shallow end-tidal C[O.sub.2] waves were displayed continuously on capnography. The LMA-Fastrach[TM] was removed and a lubricated size 6 armoured tracheal tube was inserted over the catheter successfully. The CAEC was removed and the position of the tracheal tube was confirmed by capnography and lung auscultation stethoscope. Adenotonsillectomy was completed uneventfully and the patient's perioperative course was unremarkable.


Managing the airway of a child with Crouzon's syndrome poses many risk factors. Management can be complicated by a protruding mandible, high-arched palate, tracheal ring abnormality, limited neck motion and nasopharynx narrowing (1).

It has also been reported that tracheal intubation can become more difficult because of cephaometric change following Le Fort III midfacial advancement surgery, which is routinely performed in order to improve the child's appearance and narrowed nasopharyngeal wall and to induce proper dental development (2).

LMA-Fastrach[TM] is a supraglottic airway, making ventilation and intubation possible. Its effectiveness during difficult airway management has already been demonstrated. CAEC is a catheter that is usually used for exchanging the tracheal tube, and it has a removable Rapi-Fit Adapter that permits ventilation.

Blind insertion of tracheal tube through LMA-Fastrach[TM] in this case was failed. It is assumed that the tracheal tube was impeded by arytenoid cartilage or epiglottis and then was not passed. When the LMA-Fastrach[TM] is aligned with the glottic opening, little or no resistance is encountered when passing the tracheal tube into the trachea. Apart from the LMA-Fastrach[TM] alignment to the glottis, the principal factor that determines the direction of the tracheal tube toward the glottis or away from it is the angle at which it emerges from the distal aperture of the the LMA-Fastrach[TM] (3).

Ferson et al reported that success rate for first-attempt blind tracheal intubation through the LMA-Fastrach[TM] in patients with high Cormack and Lehane grade was only 65.2%4. In this patient, failure of blind tracheal intubation through LMA-Fastrach[TM] may be due to high Cormack and Lehane grade. Also, the excessive flexibility of the size-6 armoured tracheal tube could be related due to the fact that it cannot maintain the optimal angle for insertion.

The CAEC used in the current case had a smaller inner diameter (3 mm) and was stiffer than the armoured tracheal tube, which seems to have made it more convenient to insert. In addition, CAEC has a Rapi-Fit Adapter which can be connected to the anesthetic circuit, thereby allowing ventilation through the CAEC despite severe resistance. Tracheal insertion of CAEC was confirmed by the presence of end-tidal C[O.sub.2] waves on the capnography during manual bag-ventilation.

Safe and accurate tracheal intubation can be achieved during difficult airway management with the use of LMA-Fastrach[TM] under fibreoptic bronchoscopic guidance. The problem is that fibreoptic bronchoscopy is not always available.

CAEC is valuable as an alternative to a fibreoptic bronchoscope for blind tracheal intubation through LMA-Fastrach[TM].



Daejeon, Korea


(1.) Nargozian C. The airway in patients with craniofacial 1. abnormalities. Paediatr Anaesth 2004; 14:53-59.

(2.) Roche J, Frawley G, Heggie A. Difficult tracheal intubation induced by maxillary distraction devices in craniosynostosis syndrome. Paediatr Anaesth 2002; 12:227-234.

(3.) Kundra P, Sujata N, Ravishankar M. Conventional tracheal tubes for intubation through the intubating laryngeal mask airway. Anesth Analg 2005; 100:284-288.

(4.) Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology 2001; 95:1175-1181.
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