Management of the difficult pediatric airway with endotracheal intubation via telescopic guidance.

INTRODUCTION Comprehensive airway evaluation is a critical component in the diagnosis of common pediatric conditions including laryngomalacia, vocal fold immobility, subglottic or tracheal stenosis, tracheomalacia, and recurrent respiratory papillomatosis. It is imperative in these cases that complete airway assessment from the supraglottis to bronchi be safely performed. This can be particularly challenging in neonates and small children due to their poor pulmonary reserve, as well as the presence of lesions and tissue obstructing already small airways. In addition, it is often difficult to forecast a dangerous pediatric airway, and one must be prepared to rapidly secure the airway should the need arise. Traditionally, difficult airway management in children has included rigid bronchoscopy with side port ventilation. A tracheostomy can then be performed while the rigid bronchoscope is in place. In many situations it is desirable to secure the airway while avoiding tracheostomy. However, withdrawal of the rigid bronchoscope after evaluation sacrifices airway control. Here, we describe a simple approach to airway management, in which evaluation is performed with a rigid endoscope preloaded with an endotracheal tube. This method affords high-resolution airway evaluation, while preserving the ability to immediately intubate when clinically indicated.