Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942001000300005
Brazilian Journal of Anesthesiology
Clinical Information

Dificuldade de intubação traqueal em paciente com craniossinostose: relato de caso

Tracheal intubation difficulty in patient with craniosynostosis: case report

Cláudia Luisa Gifoni; Henrique S Nascimento; Nelson Mizumoto

http://dx.doi.org/10.1590/S0034-70942001000300005 Braz J Anesthesiol, vol.51, n3, p.218-224, 2001
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Resumo

JUSTIFICATIVA E OBJETIVOS: Existem formas complexas de craniossinostose acompanhadas de malformações da face e das vias aéreas, que podem levar a dificuldade de intubação traqueal (IOT). O objetivo deste relato é apresentar um caso de intubação traqueal difícil, em criança submetida à cirurgia para correção da craniossinostose. RELATO DO CASO: Criança com 57 dias, 3700 gramas, perímetro cefálico 39 cm, ASA II, com craniossinostose, retrognatia, macroglosia e exoftalmo bilateral, dificuldade inspiratória e retração intercostal leve. Após decúbito dorsal, coxim sob os ombros, pré-oxigenação e infusão de propofol (10 mg) e succinilcolina (5 mg), realizou-se laringoscopia (lâmina nº 1 reta), sem visualização da epiglote. Foi feita ventilação assistida seguida de novas tentativas (4) de IOT, sem sucesso. Optou-se pela ventilação espontânea assistida e IOT, novamente sem sucesso. Pela capnografia não havia CO2 exalado. Com auxílio de fibroscópio intubou-se a traquéia, porém a sonda era estreita e foi trocada por outra com balonete. A SpO2 era de 98%, porém com instabilidades, ás vezes com 60%. A P ET CO2 apresentava hipocapnia com morfologia irregular. À ausculta mostrava ventilação pulmonar bilateral, porém com entrada de ar no estômago. Suspeitou-se de fístula tráqueo-esofágica traumática. Com endoscopia esofágica constatou-se que a sonda de intubação estava no esôfago; como o balonete foi insuflado na cavidade oral posterior, que estava edemaciada, impedia o vazamento de gás. O volume corrente ventilava o estômago e os pulmões simultaneamente. A sonda foi introduzida corretamente na traquéia com fibroscópio e realizou-se a cirurgia. CONCLUSÕES: É necessário distinguir craniossinostose simples daquelas acompanhadas de malformações faciais e de vias aéreas. É fundamental que se tenha equipamentos adequados para IOT e além da monitorização básica, a capnografia é de grande valor na confirmação da intubação traqueal.

Palavras-chave

DOENÇA, Neurológica: craniossinostose, INTUBAÇÃO TRAQUEAL

Abstract

BACKGROUND AND OBJECTIVES: There are complex forms craniosynostosis, some of them featuring face and airway malformations, which may lead to difficult tracheal intubation (TI). This report aimed at presenting a difficult tracheal intubation case, in a child submitted to surgery for craniosynostosis correction. CASE REPORT: Child with 57 days of age, weighing 3700 g, cephalic perimeter 39 cm, physical status ASA II, with craniosynostosis, retrognathia, macroglossia, bilateral exophthalmus, inspiratory difficulty and mild intercostal retraction. In the supine position with a pad under the shoulders, the patient was pre-oxygenated, 10 mg propofol with 5 mg succinylcholine were injected and laryngoscopy was performed (straight blade number 1) without epiglottis visualization. Assisted ventilation was started and four new unsuccessful laryngoscopies attempts were performed. We decided for allowing spontaneous assisted ventilation and a new TI was attempted, also unsuccessful. Capnography showed no exhaled CO2. With the aid of a fibroscope, trachea was finally intubated, but the tube was too narrow and was replaced by a cuffed one. SpO2 was 98% but unstable, sometimes reaching 60%. P ET CO2 showed hypocapnia and irregular curve morphology. Auscultation revealed bilateral pulmonary ventilation, but the air was reaching the stomach as well. We suspected of a traumatic tracheal-esophageal fistula. Esophageal endoscopy showed that the tube was actually in the esophagus; since the cuff was inflated in the posterior edematous oral cavity, this would prevent air leakage and allow the tidal volume to ventilate stomach and lungs simultaneously. The tube was then properly introduced in the trachea, once again with the aid of the fibroscope, and surgery was performed. CONCLUSIONS: It is important to distinguish a simple craniosynostosis from those presenting face and airway malformations. Adequate TI equipment is mandatory and, in addition to basic monitoring, capnography is of great value to confirm tracheal intubation.

Keywords

DISEASE, Neurologic: craniosynostosis, TRACHEAL INTUBATION

References

Berg K, Grundmann U, Wilhelm W. Craniosynostosis operations in childhood. Anesthesiol Intensivomed Notfallmed Schmerzther. 1997;32:138-150.

Crysdale WS, Kohli-Dang N, Mullins GC. Airway management in craniofacial surgery: experience in 542 patients. J Otolaryngol. 1987;16:207-215.

Vaughan C. Anesthetic management of children with craniofacial anomalies. CRNA. 1997;8:123-134.

Voyagis GS, Kyriakis KP, Roussaki-Danou K. Evaluating the difficult airway: An epidemiological study. Minerva Anestesiol. 1995;61:483-489.

Järund M, Lauritzen C. Craniofacial dysostosis: airway obstruction and craniofacial surgery. Scand J Plant Reconstr Surg Hand Surg. 1996;30:275-279.

Borland LM, Swan DM, Leff S. Difficult pediatric endotracheal intubation: a new approach to the retrograde technique. Anesthesiology. 1981;55:577-578.

J. Badgwell JM. Tracheal tube and laryngeal mask Placement in routine and difficult airways. Clin Pediatric Anesthesia. 1999;9:399-401.

Boufflers E, Nahhebicque V, Niset M. Téchniques d'anesthésie pour intubation difficile. Ann Fr Anesth Reanim. 1990;9:67-74.

Miyahara CM, Almeida AM, Zequi LA. Uso do broncoscópio flexível ultra-fino na intubação de crianças portadoras da síndrome de Pierre Robin. Rev Bras Anestesiol. 1996;46:267-272.

Finer NN, Muzyka D. Flexible endoscopic intubation of the neonate. Pediatr Pulmonol. 1992;12:48-51.

Miyahara CM, Gordon GJ, Gomes FC. Laringoscópio de fibra óptica: uma alternativa técnica para a intubação traqueal. Rev Bras Anestesiol. 1990;40:181-185.

Kleeman PP, Jantzen JP, Bonfils P. The ultra-thin bronchoscope in management of the difficult paediatric airway. Can J Anaesth. 1987;34:606-608.

Ovassapian A, Yelich SH, Dikes MHM. Fiberoptic nasotracheal intubation: incidence and causes of failure. Clinical reports. Anesth Analg. 1983;62:692-695.

Wrigley SR, Black AE, Sidhu VS. A fibreoptic laryngoscope for paediatric anaesthesia. Anaesthesia. 1995;50:709-712.

Orfei P, Frandina G, Patrizio A. L'impiego della maschera laringea per il controllo dele vie aeree e le intubazioni difficili in pediatria. Minerva Anaestesiol. 1999;65:561-569.

Osses H, Poblete M, Asenjo F. Laryngeal mask for difficult intubation in children. Paediatr Anaesth. 1999;9:399-401.

Golisch W, Hönig JF, Lange H. Difficult intubation due to facial malformations in a child: The laringeal mask as an aid. Anaesthesist. 1994;43:753-755.

Grzonka MA, Kleinsasser O. Intubation damage to the larynx: Manifestations, comments on pathogenesis, treatment and prevention. Laryngorhinootologie. 1996;75:70-76.

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