To the Editor:-A 17-month-old 9.5-kg boy with Pierre Robin syndrome presented for repair of a cleft palate. Anesthesia was induced with sevoflurane in oxygen, and ventilation was maintained with the help of orpharyngeal airway. However, the vocal cords could not be observed during direct laryngoscopy, and hence a #2 laryngeal mask airway was inserted. After testing the ability to ventilate the patient with moderate positive pressure via the laryngeal mask airway, 1 mg of vecuronium was administered intravenously. A fiberoptic bronchoscope (FOB; Olympus BF 3C-30, Olympus, Tokyo, Japan) was then passed into the pharynx through a self-sealing port in the elbow connector. A j-tipped guidewire was passed through the suction port of the FOB into the trachea under direct vision, and the FOB was then removed. A tube exchanger (Cook Airway Exchange Catheter with Rapi-Fit Adapter, Size 8 French, Cook Critical Care, Bloomington, IN) was passed over the guidewire into the trachea. The guidewire and laryngeal mask airway were then removed, and a 4.0-mm-ID endotracheal tube was passed over the tube exchanger into the trachea. SpO(2) was maintained between 99% and 100% during the procedure.

The use of FOBs to assist in the passage of small pediatric endotracheal tubes typically requires a small pediatric FOB that can be passed through the tube. Such FOBs are not available in all hospitals. Our intubation technique is likely to be valuable when a small pediatric FOB is not available. It also facilitates removal of the laryngeal mask airway. Similar techniques, such as passing the endotracheal tube directly over the guidewire [1] or ureteral dilator, [2] have been reported. However, a flexible guidewire seems to be an unreliable guide to the endotracheal tube. Moreover, with these techniques, it is difficult to oxygenate the patient while inserting the endotracheal tube. The use of a commercial tube exchanger, which can be used with a jet injector, can overcome this difficulty.

Keiichi Nitahara, M.D.

Ryuiku Watanabe, M.D.

Kiyoshi Katori, M.D.

Masatomo Yamasato, M.D.

Matsuko Matsunaga, M.D.

Kenjiro Dan, M.D.

Department of Anesthesiology; School of Medicine; Fukuoka University; 7–45–1 Nanakuma; Jonan-ku, Fukuoka-shi, Fukuoka, 814–0180, Japan;

(Accepted for publication March 23, 1999.)

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