Airway Management for the Unborn Patient

Corey W. Iqbal, MD, FAAP

Objectives

• What is an EXIT procedure

• Indications

• Procedural considerations– Preoperative– Intraoperative– Postoperative

• Not that important

Fetal Airway

E.X.I.T. Procedure

Historical Perspective

History of Fetal Surgery

• Michael R. Harrison – 1981 “Father of Fetal Surgery”

• Bladder Obstruction• CDH

Pulmonary Hypoplasia

CDH

• 70% survival– Pulm hypoplasia– Pulm HTN

CHAOS

Managing the Airway

OOPS!!!

• Operation On Placental Support

• Ex-utero Intra-partum Therapy (EXIT)

NOT A CESAREAN SECTION

EXIT

• Placental Circulation– Placenta as bypass pump

• Uterine atony– Deep general anesthesia– Tocolytics

• Hemorrhage risk*

Cesarean

• Uterine contraction• No placental circulation• Regional anesthesia• “Slash & Dash”

Indications

• Any anomaly where cardiopulmonary collapse off placental/fetal circulation– Airway

• Fetal neck mass

• CHAOS

• Micrognathia

– Thoracic lesions• Lung lesions

• CDH

– Congenital heart disease– SCT

EXIT-to-???

• EXIT-to-airway– Oral endotracheal– Trachesotomy

• EXIT-to-resection

• EXIT-to-ECMO

Fetal Considerations

– Pain – fetal cocktail– Monitoring

• US• Pulse Oximetry• Temperature

– Venous access

Maternal Considerations

• DVT risk• Position – right side up• Epidural• DEEP general anesthesia

– Uterine atony

• Tocolytics– Nitroglycerin– Terbutaline

• Hemorrhage risk

Preoperative

• Patient selection

• Fetal Neck Mass– Obtain MRI – repeat between 30-34 weeks– TEDI score >12– Teratoma– Polyhydramnios

Cass et al. JPS. 2012;47:46-50

Fetal Neck Mass

• Survival without EXIT– 0-20%

• Survival with EXIT– 83%

• ALL EXITs – UCSF survival 71%

Iqbal et al. In Submission

Fetal Neck Mass

• 36 year old

Fetal MRI

Aerodigestive Compression

Deviated Trachea Small Stomach

Intraoperative

• Low transverse incision to expose uterus

• Placental mapping by ultrasound

• Hysterotomy

• Tocolytics– Nitro– Terbutaline

Intraoperative

Intraoperative

• Fetal cocktail– Fentanyl + rocuronium

• Pulse oximetry– HR– SpO2

• Temp probe

• +/-Fetal IV access– Pressors: epi, atropine– Fluid resuscitation

Intraoperative

Other Indications

• CDH – Boston data does not support– EXIT-to-ECMO: 33% vs 50% survival

• Lung lesions– 100% survival; discharge at 10 days– 71% survival without EXIT

Buchmiller et al. JPS. 2012;47:1053-1057

Lee et al. JPS. 2013;48:138-144

Other Indications

• Congenital Heart Disease– HLHS with in tact septum– Delivery in OR with immediate cath

• Other neoplasms– SCT– Little data to support

Congenital Lung Lesions

Delivery

• Secure airway – paralytics on board

• Clamp chord and deliver– Obtain chord blood gas

• Anesthesia– Reduce inhalation– Administer pitocin

• Now becomes a Cesarean

Crowd Control

Postoperative

• Mom C-sxn– Pain control– ADAT– 4 days

• Baby– Work-up– Definitive treatment

Other Scenarios

• CHAOS– Fetoscopy

Fetal Bronchoscopy

Questions