Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis.

OBJECTIVES: To review perioperative airway management and ventilation strategy during the surgical removal of papilloma under suspension laryngoscopy in pediatric patients with severe airway obstruction.

METHODS: Seventy pediatric patients with degree III and IV laryngeal obstruction who underwent suspension laryngoscopy to remove laryngeal papillomatosis, between July 2005 and March 2009, were included in the study. All patients were intubated initially to secure the airway. Controlled ventilation through an endotracheal (ET) tube was used during the papilloma debulking near the glottis vera. Spontaneous ventilation or apneic technique was adopted based on the stage of the surgical procedure and the location of the remaining tumor. Hemodynamic parameters, pulse oxygen saturation (SpO(2)), and CO(2) were closely monitored, and adverse events were recorded.

RESULTS: The duration of the surgical operation and the duration of the extubation period were 5-35 min and 5-20 min, respectively. Thirty cases with degree III and twenty cases with degree IV laryngeal obstruction received inhalation induction. Sixteen cases with degree III laryngeal obstruction were given an intravenous induction. Four patients admitted with a comatose status were emergently intubated without any anesthetics. The ET tube size was determined by assessing the opening through the tumor mass or glottic aperture under direct laryngoscopy. SpO(2) was maintained above 97% after the airway was secured and sufficient ventilation established. Controlled ventilation was used in all children during the bulk removal of tumor. Spontaneous respiration and apneic technique were adopted for the removal of the remaining tumor in the hypolarynx or trachea in 16 and 28 cases, respectively. Three patients had to be re-intubated postoperatively because of persistent desaturation or laryngospasm.

CONCLUSION: Key points of perioperative airway management in pediatric patients with papillomatosis-induced severe laryngeal obstruction include careful preoperative airway evaluation; the proper choice of induction methods, and ET tube size; maintenance of an adequate depth of anesthesia; and flexible ventilation strategy, continuous and close monitoring during the extubation and postextubation period; and prompt management of adverse events.