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
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