330 LETTERSTOTHEEDITOR
Multimodal
therapy
for
the
management
of
the
difficult
pediatric
airway
Terapia
multimodal
para
manejo
de
via
aérea
pediátrica
difícil
DearEditor,
We read with interest the case report of Fuentes et al.1
concerningtheuseofafiberopticintubationmethodthrough aLaryngeal MaskAirway(LMA) in aninfant withTreacher CollinsSyndrome.Icongratulatethemonthepresentation ofthecase.Iwouldliketoaddsomecomments.
Treacher Collins syndrome is an autosomal dominant craniofacialdevelopmentdisordercharacterizedbysevere defectsthat create a difficult airway. Failure of tracheal intubationremainsaleadingcauseofmorbidityand mortal-ity.Differentdevicesandtechniqueshavebeendeveloped to assist this problem. However, all of them have disad-vantagesand nodevice is infalliblein allcircumstances.2
Thus, the failures of each, when used alone, are more frequently reported, as this case, but the combined use canovercomeindividuallimitations increasingthesuccess rate.3Currently,thereisagrowingtendencytouse
Fiberop-ticBronchoscope (FOB) in combination with other airway techniques as a multimodal approach to difficult airway management.
The combined use of an FOB and a LMA, as Fuentes etal.describes,haveseveraladvantages.TheILMAensure ventilationand isolate theairway ofpossible presence of secretions or blood in an emergent context,4 and onthe
otherhand,ifitseat properly,LMAissituated aroundthe glottisandprovidesapathwayfortheFOB,facilitatingits maneuverability.
Likewise, FOB may be combined with Video Laryngo-scopes(VL)toreduceruntimeandtomaximizethesuccess ofendotrachealintubation.5Thus,throughthismultimodal
therapy,theVLprovidesanunobstructedroutetoFOB, plac-ingitinthevicinityoftheglottisandallowsvisualizationof theadvanceofETTonFOBthroughthevocalcords,while theFOBcanovercometheexistingacuteanglebetweenthe ETTandtheglottis.3
Bothmethods aresuccessfulinreducingthenumberof interventionsin the airway and thus, the likelihood of a dramatic‘‘cannotintubate,cannotventilate’’scenario.
The multimodal approachtothe airway is increasingly accepted.TheabilityoftheFOBtobecombinedwithmany
otherairwaydevicesisincomparable.Thecombineduseof airwaytechniquesshouldbehighonthepriorityoptionfor rescueofdifficultFOBintubationorasprimaryapproachfor themanagementofthedifficultpediatricairway.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Fuentes R, De la Cuadra JC, Lacassie H, et al. Diffi-cult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome. Rev Bras Anestesiol. 2015,
http://dx.doi.org/10.1016/j.bjane.2015.02.004[inpress]. 2.Gómez-Ríos MÁ. Can fiberoptic bronchoscopy be replaced by
videolaryngoscopyinthemanagementofdifficultairway?Rev EspAnestesiolReanim.2016;63:189---91.
3.Gómez-RíosMA,NietoSerradillaL.CombineduseofanAirtraq®
optical laryngoscope, Airtraq video camera, Airtraq wireless monitor,andafibreopticbronchoscopeafterfailedtracheal intu-bation.CanJAnaesth.2011;58:411---2.
4.MichalekP, HodgkinsonP, Donaldson W. Fiberoptic intubation throughanI-gelsupraglotticairway intwo patientswith pre-dicteddifficultairwayandintellectualdisability.AnesthAnalg. 2008;106:1501---4.
5.KarsliC.Managingthechallengingpediatricairway:Continuing ProfessionalDevelopment.CanJAnaesth.2015;62:1000---16.
ManuelÁngelGómez-Ríosa,b,∗,ClaraMarín-Zaldívara,David
Gómez-Ríosa,AlbertoPensado-Casti˜neirasa
aDepartmentofAnesthesiologyandPerioperative
Medicine,ComplejoHospitalarioUniversitariodeA Coru˜na,ACoru˜na,Galicia,Spain
bInstitutodeInvestigaciónBiomédicadeACoru˜na(INIBIC),
GrupodeInvestigación‘‘AnestesiologíayTratamientodel Dolor’’,ACoru˜na,Spain
∗Correspondingauthor.
E-mail:magoris@hotmail.com(M.Á.Gómez-Ríos). Availableonline12May2016
http://dx.doi.org/10.1016/j.bjane.2016.02.002
0104-0014/
©2016SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense
