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LETTER TO EDITOR
Year : 2018  |  Volume : 62  |  Issue : 6  |  Page : 473-474  

Air- Q intubating laryngeal airway guided intubation in Morquio syndrome


Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Sadik Mohammed
3rd Floor, OPD Block, All India Institute of Medical Sciences, Basani Phase II, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_465_17

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How to cite this article:
Mohammed S, Gupta SK, Bhatia PK, Chhabra S, Sethi P, Chouhan RS. Air- Q intubating laryngeal airway guided intubation in Morquio syndrome. Indian J Anaesth 2018;62:473-4

How to cite this URL:
Mohammed S, Gupta SK, Bhatia PK, Chhabra S, Sethi P, Chouhan RS. Air- Q intubating laryngeal airway guided intubation in Morquio syndrome. Indian J Anaesth [serial online] 2018 [cited 2018 Jun 18];62:473-4. Available from: http://www.ijaweb.org/text.asp?2018/62/6/473/234021



Sir,

Mucopolysaccharidoses (MPS) are lysosomal storage disorders caused by the deficiency of enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs), also known as mucopolysaccharides. Patients with MPS may develop complications during general anaesthesia (GA) due to the presence of airway obstruction, excessive secretions, a large tongue and an abnormal airway anatomy. Patients with MPS type IV, also known as Morquio syndrome, pose even greater challenge because of additional problems such as neck instability, restrictive pulmonary disease and end-organ damage.

A 16-year-old male patient (weight: 27 kg; height: 135 cm) diagnosed with  Morquio-Brailsford syndrome More Details was posted for valgus osteotomy of femur. He was found to have short stature, small barrel chest with pectus carinatum, large head with small neck and kyphoscoliosis of lower thoracic and lumbar vertebrae [Figure 1]a. He was operated for congenital bilateral dislocation of hip at the age of 3 and 4 years, respectively, under GA for which no records were available. He had normal intellectual development and had cleared secondary school examination recently. Airway examination revealed Grade 2 macroglossia, an enlarged uvula and tonsils, Mallampati Grade II and adequate neck flexion with restricted extension [Figure 1]b. Examinations of the rest of the systems were normal. As the patient refused to receive spinal anaesthesia, awake fibreoptic intubation (AFOI) was planned. Both the nares were prepared and the patient was pre-medicated with glycopyrrolate 0.2 mg, midazolam 1 mg and fentanyl 50 μg. Attempt at inserting the fibreoptic bronchoscope (FOB) resulted in trauma leading to blood tinged secretions, which precluded the view. After two failed AFOI attempts, GA was induced with propofol 60 mg and Air-Q Intubating Laryngeal Airway™ (Cook gas LLC, Mercury Medical, Clearwater, FL, USA) #2.5 was inserted with manual inline stabilisation of cervical spine and its position was confirmed with FOB, capnograph and auscultation. A 5.5 mm ID cuffed endotracheal tube (ETT) was railroaded over FOB through the Air-Q ILA, and both the devices were secured in place [Figure 1]c. Surgery lasted for more than 2 h with stable intraoperative vitals. At the end of surgery, the ETT was removed and ventilation was continued via Air Q ILA. Neuromuscular blockade was reversed and Air Q ILA was removed once the patient was fully awake.
Figure 1: (a) Body habitus of the patient; (b) restricted neck extension and large Tongue with Mallampati Grade II (c) Air-Q ILA and endotracheal tube in place

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MPS type IV also known as “Morquio syndrome” is an autosomal recessive disorder caused by the deficiency of n-acetylgalactosamine-6-sulphate leading to deposition of large amount of keratan sulphate and chondroitin sulphate in various tissues of body. At birth, child with Morquio syndrome may appear healthy; however, as they grow, progressive mesenchymal deposition of GAG results in appearance of manifestations of the syndrome. The incidence of difficult intubation in patients with Morquio syndrome varies from 0% to 50%, and airway difficulty progresses as age advances due to accumulation of keratan sulphate.[1] Hence, previous anaesthesia records of surgery with no difficulty in airway could be misleading. In our case, the patient had previous history of anaesthetic exposure, but the record was not available. Case reports concerning the airway management in patient with Morquio syndrome have been reported in the literature.[2] Most authors recommended AFOI- or FOB-guided intubation after induction. However, FOB-guided intubation without any airway conduit may be extremely difficult as these patients may have a “hanging epiglottis” making passage of fibrescope toward the glottis impossible.[3] Dhanger et al. reported successful I-gel-guided fibreoptic intubation in patient with Morquio syndrome.[2] However, I-gel™ requires greater mouth opening for insertion and one may face difficulty in its removal after intubation.[4] In our patient, we decided to intubate as there was a possibility of change in the patient position to lateral decubitus during intraoperative period. After the failed AFOI attempt, our choice of Air-Q ILA™ was advantageous because of its ability to be inserted without any head extension, to be left in situ during ventilation through ETT and to be used as conduit for ventilation after ETT removal. The Air-Q ILA™ has proved to be a safe supraglottic airway device in children with difficult airway as it has low potential for trauma of the airway and it can be used as a facilitator for blind endotracheal intubation.[5] The special feature of Air-Q ILA include a larger diameter and shorter length of airway tube allowing intubation with a standard ETT of age appropriate size and removal of the device following intubation does not require aid of stabilizing rod.

We used Air-Q ILA™-guided intubation as an alternative to AFOI in patients with Morquio syndrome. Insertion of Air-Q ILA™ did not require neck extension and was left in place to serve as an additional conduit for ventilation after extubation. Thus, Air-Q ILA™ provided safe intubation and extubation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

We would like to acknowledge the support of Dr. Ranvindra Singh Chouhan, Senior Resident, Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Theroux MC, Nerker T, Ditro C, Mackenzie WG. Anesthetic care and perioperative complications of children with Morquio syndrome. Paediatr Anaesth 2012;22:901-7.  Back to cited text no. 1
[PUBMED]    
2.
Dhanger S, Adinarayanan S, Vinayagam S, Kumar MP. I-gel assisted fiberoptic intubation in a child with Morquio's syndrome. Saudi J Anaesth 2015;9:217-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Kadic L, Driessen JJ. General anaesthesia in an adult patient with Morquio syndrom with emphasis on airway issues. Bosn J Basic Med Sci 2012;12:130-3.  Back to cited text no. 3
[PUBMED]    
4.
Sharma S, Scott S, Rogers R, Popat M. The i-gel airway for ventilation and rescue intubation. Anaesthesia 2007;62:419-20.  Back to cited text no. 4
[PUBMED]    
5.
El-Ganzouri AR, Marzouk S, Abdelalem N, Yousef M. Blind versus fiberoptic laryngoscopic intubation through air Q laryngeal mask airway. Egypt J Anaesth 2011;27:213-8.  Back to cited text no. 5
    


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