Perinatal/Neonatal Case Presentation

Preoperative airway management in a preterm with bilateral choanal atresia

Abstract

Bilateral choanal atresia (CA) is a recognized neonatal emergency. Before corrective surgery, provision of a secure airway is crucial. No approach has been specifically advocated for preterm infants. We describe successful use of a novel airway in a preterm infant with CA.

Introduction

Newborn infants are obligate nasal breathers and bilateral choanal atresia (CA) is a recognized neonatal emergency.1, 2 Incidence of CA is 1 in 5000 to 7000 live births with a ratio of 2:1 (unilateral/bilateral).3 CA has been reported in both monozygotic and dizygotic twins, but there is no increased incidence of CA in twin pregnancy.4, 5, 6 Corrective surgery is the only recognized treatment for CA. Providing a secure airway is usually a short-term solution.7 However, in preterm infants corrective surgery may need to be delayed depending on the weight and gestation. It is therefore essential to maintain the upper airway until corrective surgery can be performed. An extensive literature search revealed several methods of maintaining the upper airway in term infants with bilateral CA, but none mentioning preterm infants. The methods used for term infants were impractical in our preterm infant with bilateral CA. We report an innovative technique to maintain the airway in a preterm infant until corrective surgery was performed.

Case

A female infant, twin 2 of dichorionic, diamniotic twins born by emergency caesarean section at 33 weeks gestation with birth weight 2350 g was noted to have profound cyclical desaturations with thick oral secretions at birth. Mother had an uneventful pregnancy and after spontaneously going into labour received one course of antenatal steroids. Emergency caesarean section was performed for breech presentation in twin 1. Antenatal scanning showed no anomalies and normal liquor volume in both twins. Owing to frequent desaturations and bradycardias, twin 2 was intubated, ventilated and admitted to the neonatal intensive care unit. Shortly after admission, the infant self-extubated. Her breathing was laboured with prominent suprasternal, intercostal and subcostal recessions post-extubation. Attempts at passing size 4F nasogastric tube through both nostrils were unsuccessful. A diagnosis of bilateral CA was suspected and subsequently confirmed by computerized tomography imaging of the nasopharynx (Figure 1). No other dysmorphic features or abnormalities were noted.

Figure 1
figure1

Computerized tomography scan of the preterm infant showing bilateral CA. The black arrows point to the areas of atresia.

She was reintubated and commenced on synchronized intermittent mandatory ventilation and subsequently on endotracheal continuous positive airway pressure. A Guedel oro-pharyngeal airway was tried; however, thick mucous secretions continued to be a significant problem and it was difficult to secure. Therefore a soft 4.0 mm endotracheal tube was used as an oro-pharyngeal airway. The length of the airway residing in the oral cavity was estimated by measuring the distance from the angle of the mouth to the tragus. The final satisfactory position was confirmed using direct laryngoscopy. The airway was secured and to provide humidity to the inhaled air, a thermal humidifying filter or Swedish nose was fitted to the end. A Y-connection to the tube allowed for in-line suctioning (Figure 2). The infant tolerated this airway extremely well with a reduction in the thick mucous secretions, minimal respiratory distress and normal blood gases suggesting adequate and comfortable ventilation. The airway was changed once due to dislodgement.

Figure 2
figure2

The assembly of the airway used preoperatively in the preterm infant with bilateral CA.

The infant's karyotype was 46XX. She had normal eye examination, hearing screen and echocardiogram. Renal ultrasound revealed mild unilateral hydronephrosis. There was no evidence of CA in twin 1.

The infant remained on this airway until day 23 of life when she had surgical correction. During her preoperative period, nutrition was maintained through orogastric tube feeding and corrective surgery was performed when she reached 2500 g. She had successful laser surgery of the posterior choanae followed by insertion of portex stents to maintain patency. The post surgical course was uneventful and she was discharged home breathing by herself on day 32 of life. At her 3-month follow-up, she was thriving and no complications were noted.

Discussion

Bilateral CA is a rare neonatal emergency. It is vital to maintain the airway until corrective surgery. To our knowledge, the only methods described in the literature for preoperative management of the airway in term infants with bilateral CA are:

  1. a)

    A typical anaesthetic oral airway (for example, Guedel airway). This is difficult to secure and is not tolerated well by the preterm infant as was found in our infant.

  2. b)

    A large bore (12 or 14F) orogastric tube to break the obstructive seal between the tongue and the soft palate. However, this technique is met with only moderate success.8

  3. c)

    The McGovern nipple has been described as a secure method of maintaining the airway.9 A large modified feeding teat with a hole in the end is secured using ties around the occiput.

  4. d)

    Tracheostomy may be necessary in some infants with bilateral CA.10 However, this is an invasive procedure.

There are no reported alternatives for preterm infants with bilateral CA. Securing the airway satisfactorily in smaller infants is a significant problem. We also note that there is no way of humidifying the air when using the first three methods. This may exaggerate the problems of thick mucous secretions that commonly occur in bilateral CA.

The most important benefits of our method are the ease of securing the airway and allowing humidification through the thermal humidifying filter or the Swedish nose and thereby reducing secretions. The Y-connector allows for suctioning.

Although this airway was useful in our infant, we recognize two possible disadvantages:

  1. a)

    Thermal humidifying filter or the Swedish nose increases resistance and dead space and so might increase the work of breathing in the infant. This may possibly lead to early tiring of preterm infants.

  2. b)

    Like any other pharyngeal airway it may cause stimulation of the gag reflex.

In conclusion, the benefits of this airway outweigh the disadvantages. It requires readily available equipment, is easy to secure and provides a stable and comfortable airway. The potential advantage of humidifying the air and providing in-line closed suction reduces the risk of desaturations and/or mucous plugging from thick oral secretions.

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Correspondence to S V Godambe.

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Fulton, R., Banerjee, J., Chow, P. et al. Preoperative airway management in a preterm with bilateral choanal atresia. J Perinatol 27, 521–522 (2007). https://doi.org/10.1038/sj.jp.7211778

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Keywords

  • airway
  • preoperative
  • preterm
  • infant
  • choanal atresia
  • bilateral

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