The air‐Q ® intubating laryngeal airway for endotracheal intubation in children with difficult airway: our experience

SIR—We read with interest and true appreciation both the article by Jagannathan N et al. (1) and the comment by Parotto M et al. (2) as well as the recent article by Jagannathan N et al. (3) where they reported their experience with air-Q intubating laryngeal airway (ILA) (Cookgas , LLC St Louis, MO, Mercury Medical , Clearwater, FL, USA) as a conduit for laryngeal mask-assisted tracheal intubation in patients with difficult airway. It is a novel supraglottic airway device recently introduced into the anesthesia’s market, designed to perform a guidance for tracheal intubation with a cuffed tracheal tube and to facilitate its removal by a custom stylet. At once, we were intrigued by the described easy use of this novel device to perform a fiberoptic intubation in pediatric patients with difficult laringoscopy. Therefore, we also begun to employ it from March 2009 to September 2011 in infants and children with documented or predictable difficult direct laryngoscopy scheduled for surgery where it was indispensable to perform an endotracheal intubation, especially for craniomaxillo-facial reconstructive surgery of congenital malformations. We are describing our experience in anesthesia care of 12 patients with difficult airways. The median age was 78.7 (1–160) months and the median weight was 23.8 (2.5–50) kilograms. All patients (ASA I-II) were premedicated by oral midazolam 0.2 mgÆkg 4500 prior to their admittance into the operating room and received 0.01 mgÆkg of IV atropine sulfate to minimize secretions as soon as a vascular access was established after performing general anesthesia by volatile agents such as sevoflurane 3–5% in 40% oxygen/60% nitrous oxide gas mixture via face mask, while patients breathe spontaneously. The air-Q ILA, without deflating cuff, was easily inserted with the index finger of the right hand, while the anesthetist performed jaw’s lift with left hand, without a rotational technique. A flexible fiberoptic bronchoscope (FOB), preloaded with a well lubricated by KY Jelly (Johnson & Johnson Medical, New Brunswick, NJ, USA) cuffed oral endotracheal tube (ETT), was inserted into the lumen of the air-Q ILA after removing the circuit connector. The larynx was always easily visualized as the bronchoscope traveled outside the air-Q ILA. Before going beyond vocal cords, an IV bolus of propofol 2 mgÆkg was injected prior to advance FOB to carina. Then, ETT was slid over the scope through the air-Q ILA into trachea. Positioning of ETT was confirmed by FOB visualization, end-tidal C02 and lung sounds. In case of craniomaxillo-facial surgery, we easily removed air-Q ILA using a specially designed removal stylet to prevent dislodging the ETT during this maneuvre. Otherwise the laryngeal mask was left in the mouth. In summary, we fully agree with Authors that airQ ILA may be a well-suited alternative to the classic laryngeal mask in children with difficult airway, especially when an ETT is required.