Authors: Amarante Dias C et al.
Cureus 18(2): e104314 10.7759/cureus.104314
Summary
This case report describes a 14-year-old girl (44 kg) with a large cervical venous malformation extending into the pharyngeal mucosa who underwent sclerotherapy with bleomycin and polidocanol. The malformation caused oropharyngeal compression and posed a high risk of bleeding with direct laryngoscopy or supraglottic airway use.
An awake fiberoptic intubation was performed under ketamine and dexmedetomidine sedation with topical lidocaine. Sedation was titrated to a UMSS score of 2–3, preserving spontaneous ventilation. Intubation was uneventful. Due to anticipated postoperative edema and risk of airway compromise, extubation was deferred and the patient remained intubated in the PICU.
On postoperative day 5, airway assessment revealed significant edema and corticosteroid therapy was initiated. By postoperative day 6, edema had resolved, but residual malformation still rendered laryngoscopy unsafe. Because reintubation was expected to be difficult and bleeding risk remained high, a staged extubation strategy was selected using a Cook Staged Extubation Set (CSES).
The staged extubation wire was positioned at the same depth as the endotracheal tube, and the tube was removed while leaving the guidewire in situ as a conduit for rapid reintubation if needed. The patient was continuously monitored. Aside from transient hypersalivation treated with atropine, no complications occurred. The wire remained in place for 12 hours without respiratory compromise and was subsequently removed. No reintubation was required.
The authors note that while adult difficult airway guidelines endorse extubation conduits, pediatric data are sparse. To their knowledge, this is the first published pediatric case reporting use of the full CSES for planned extubation of an anatomically difficult airway.
Key Points
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Extubation may carry higher complication risk than intubation in pediatric anesthesia.
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In anatomically difficult pediatric airways, especially with bleeding risk, extubation requires structured planning.
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The Cook Staged Extubation Set allows maintenance of a tracheal guidewire after tube removal, facilitating rapid reintubation without laryngoscopy.
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In this cooperative adolescent, the device was tolerated for 12 hours without adverse events.
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Pediatric evidence for staged extubation devices remains limited; most literature is adult-based.
What You Should Know
This case reinforces an important principle: difficult airway management does not end with intubation. Extubation is often the higher-risk moment, particularly in children with residual anatomical distortion, edema, or vascular lesions.
For selected cooperative adolescents in an ICU setting:
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A staged extubation wire can provide a safety margin.
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Continuous monitoring and multidisciplinary planning are essential.
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This strategy should be limited to centers experienced in pediatric difficult airway management.
There is still no robust pediatric evidence base defining ideal dwell time, complication rates, or reintubation success with CSES. But conceptually, for high-stakes airways, proactive extubation planning deserves the same rigor as awake intubation strategy.
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