Management of Difficult Airway in Pediatrics with Laryngomalacia

Abstract

Introduction: Laryngomalacia is a condition in which the larynx (the base of the throat) does not develop normally, leading to breathing difficulties in children. The condition of laryngomalacia invites intubation to overcome airway obstruction that has the potential to cause laryngeal stenosis. Laryngeal stenosis in children, which can result from various factors including prolonged intubation, repeated intubation procedures, and laryngomalacia, is a major contributor to airway obstruction in children.

Objectives: This case report aims to explain the presence of laryngomalacia in a child, which was later found to have progressed to laryngeal stenosis.

Case: A 1-year and 5-month-old female patient, weighing 8.5 kg and measuring 74 cm in height, was presented as a case. The patient had a prior diagnosis of postoperative stoma status following a limited PSARP procedure and was concurrently affected by an anorectal malformation vestibular fistula. Additionally, the patient exhibited congenital anomalies, including mesocardiac abnormalities, a single right kidney, hypothyroidism, and laryngomalacia. The patient also had the history of prolonged and intubation when she was 3 months old due to pneumonia, and the history of repeated attempts of intubation for the first two surgeries. The preoperative assessment revealed signs of pneumonia, right lung atelectasis, and a history of laryngomalacia. In the preoperative assessment, the patient was found breathing spontaneously, with respiratory rate around 24-28 times per minute, no desaturation was found. The patient has inspiratory stridor, which worsens during feeding and moderate activity. No retraction of the chest or use of respiratory accessory muscles were found. The patient was evaluated for postoperative ICU care during the preoperative consultation as a precaution for chances of laryngeal edema post intubation and unanticipated airway event during anesthesia.

Results: In specific cases, as described in this manuscript, anesthesia procedures become crucial, and specialized equipment such as LMA (Laryngeal Mask Airway) and fiberoptic laryngoscope are used to address difficult airways. However, the use of LMA also has potential pitfalls, such as requiring a large tidal volume and not allowing the use of NGT (Nasogastric Tube) for abdominal decompression. Moreover, a history of repeated intubation attempts can lead to laryngeal edema, which requires management with steroids and adrenaline nebulization. However, the use of steroids and adrenaline does not always yield valid therapeutic effects, and there is a debate regarding the best approach. In specific patient cases, observation for one hour after extubation is necessary before deciding on reintubation.

Conclusions: In the cases described in the manuscript, the patient showed improvement after the use of adrenaline nebulization and intravenous steroids for 24 hours post-extubation. This allowed the patient to be transferred to a lower level of care after five days of treatment.