Difficult airway management – an old challenge: a case report

Introduction: Obtaining a secured airway is a vital aspect during reconstructive surgery in patients with extensive post-burn mentosternal scar contractures. Such contractures can potentially lead to a “can’t intubate, can’t ventilate” scenario, otherwise rare but life-threatening situation. We present a case of successful management of a paediatric case of anticipated difficult airway due to burn injury. Case description: A 14-year-old boy presented for repair of an extensive skin contracture of the neck, thorax and face due to mutilating scarring. The boy was treated for 80% burn caused by gasoline flame 14 months prior to this surgery. Burn healing and scarring resulted in massive distortion of the facial and cervical anatomy, all implying difficult airway with a high probability of “can’t intubate, can’t ventilate” situation. Flexible fiberoptic bronchoscope with loaded cuffed endotracheal tube N° 6.0 was used for visualisation of vocal cords through the mouth in light sedation with spontaneous breathing. After visualisation of the vocal cords, fentanyl (Fentanyl, GlaxoSmithKline) and thiopental (Thiopental, Rotexmedica) were administered and the trachea was intubated at the first attempt. Balanced general anaesthesia was initiated and planned surgical procedure was successfully completed. The trachea was extubated on the first postoperative day without any complication. Conclusion: Difficult paediatric airway and particularly “can’t intubate, can’t ventilate” situation is a problem associated with significant risks and complications. Anticipating a difficult airway, having a structured approach with appropriate preparation, and understanding of difficult airway management algorithms are essential for success.