Neonatal Airway: No Bypass to Preparedness, Presence, and Prudence

The field of neonatal anesthesia is arduous owing to the vulnerability of the population that requires compassion, the requirement of specialized techniques and expertise of care, and a commitment to the hopes of anguished parents.

In the context of the article Giant Cystic Hygroma in a Neonate-Fixing the Trajectory: Manual Maneuver for Airway Rescue,^[1] our anesthetic knowledge about cervical cystic hygroma prepares us beforehand for the unique airway challenges^[2,3] which has been adequately highlighted by the authors. However, in contrast to as emphasized by the authors, it is not only the period of intubation which requires vigilance but also a meticulous preanesthetic checkup with a comprehensive imaging to define size, intrathoracic extension, and tracheal distortion preoperatively forms an indispensable part of the perioperative preparation. This helps us in formulating the alternative strategies for airway management.

Perhaps the difficult airway cart was ill-prepared. It needs to be emphasized that alternative strategies such as supraglottic device should be available in case of failed mask ventilation and spontaneous ventilation should be maintained for the fear of the loss of airway. The authors also did not indicate if paraoxygenation, a recommended component of neonatal airway management, was employed.^[4]

Nevertheless, the authors^[1] have astutely observed that it is not just the visualization of the glottis that is hampered; an interference with the endotracheal tube (ET) trajectory may also contribute to a difficult airway situation which was adequately taken care of by simple external manipulation of the mass. We fail to recognize that basic maneuvers such as lateral or semi-prone positioning, jaw thrust, and gentle external manipulation of the mass and/or larynx may help mitigate an emergency till expert help is available, especially in remote locations such as magnetic resonance imaging suites and ill-equipped centers. Unfortunately, the authors fail to describe and give a pictorial description of the external manipulation done for the benefit of the readers. However, let us acknowledge that literature is replete where such rescue maneuvers were performed.^[5]

Furthermore, the authors nowhere mentioned if the neonate was properly positioned using a shoulder roll, if intubation was performed by an expert in the field or if an age-appropriate bougie was available which could have expedited the negotiation of the tube through the glottis. This would have reduced repeated attempts at laryngoscopy associated with sympathetic stimulation, trauma to fragile mucosa, and edema that have their own catastrophic effects. The authors could have also obtained a grade II view of the glottis using a videolaryngoscope for better alignment of the ET trajectory.^[6]

They also failed to elaborate on their planned sequential steps in the event of failure of the initial airway management approach.

Apart from the above, careful intraoperative maintenance of endotracheal tube position, and a safe extubation plan, given the risk of airway obstruction, are key to effective airway management.

Finally, an infographic depicting airway problems that could be encountered in neonatal cystic hygroma; strategy, equipment, and non-technical skills needed to overcome the same would have tremendously made the case report an interesting read.

To conclude, the airway in neonatal cervical masses has its own unique challenges and requires meticulous task management, multidisciplinary involvement, and a pragmatic crisis handling approach.