Authors: Macedo-Campos R et al.
Cureus, June 16, 2026.
Summary
This case report describes the management of an extremely premature infant with an unexpectedly difficult airway who experienced two cardiac arrests during separate attempts at tracheal intubation.
The patient was born at 27 weeks and 4 days of gestation with a birth weight of 922 g. He later required gastrointestinal reconstruction surgery. At the time of the first planned procedure, there were no known predictors of a difficult airway.
After induction of general anesthesia, two videolaryngoscopic attempts and one conventional laryngoscopic attempt failed. A Cormack-Lehane grade IV view was reported. Although facemask ventilation was initially effective, ventilation became more difficult after repeated airway manipulation.
The infant developed severe oxygen desaturation and bradycardia, followed by asystolic cardiac arrest. Cardiopulmonary resuscitation was initiated, an appropriately sized i-gel laryngeal mask was inserted, and epinephrine was administered. Return of spontaneous circulation occurred after one resuscitation cycle, and surgery was postponed.
When the patient returned for surgery approximately two months later, the difficult airway was anticipated. A multidisciplinary team consisting of two senior anesthesiologists, a neonatologist, and a physician experienced in pediatric fiberoptic bronchoscopy developed a stepwise airway plan.
The strategy prioritized preservation of spontaneous ventilation and included:
• Initial fiberoptic intubation
• Fiberoptic intubation through a laryngeal mask if the first attempt failed
• Postponement and consideration of a surgical airway if both approaches failed
All equipment was tested for size compatibility before induction.
During the second procedure, a direct fiberoptic attempt revealed a deformed epiglottis and markedly anterior vocal cords. The attempt was complicated by bronchospasm, severe desaturation, and another cardiac arrest. Return of spontaneous circulation occurred after approximately two minutes of CPR and one dose of epinephrine.
Ventilation was restored with a size 1 i-gel laryngeal mask. After stabilization, the fiberoptic bronchoscope was passed through the laryngeal mask, and a 3.0 cuffed endotracheal tube was successfully placed.
Because of the short working length and equipment limitations, two 3.0 endotracheal tubes were mounted consecutively over the bronchoscope. The proximal tube was used to advance the definitive tube into the trachea using a Seldinger-style technique.
The operation was then completed successfully. The infant remained intubated for 48 hours and was subsequently extubated without complications.
What You Should Know
Neonatal airway difficulty may occur unexpectedly, even when no conventional predictors are present.
Premature infants have limited functional residual capacity, high oxygen consumption, and very little physiologic reserve. They may deteriorate rapidly during apnea or airway obstruction.
Repeated intubation attempts can cause airway edema, bleeding, worsening visualization, and progressive loss of effective ventilation.
Oxygenation should take priority over repeated efforts to place an endotracheal tube.
Supraglottic airway devices can be lifesaving rescue tools and may also serve as conduits for fiberoptic intubation.
Fiberoptic intubation through a laryngeal mask can permit continued oxygenation, reduce repeated direct airway manipulation, and provide a more stable route toward the larynx.
Maintaining spontaneous ventilation may provide an additional margin of safety when managing an anticipated difficult neonatal airway.
Equipment compatibility must be confirmed before induction because neonatal bronchoscopes, endotracheal tubes, and supraglottic devices may not fit together as expected.
A predefined escalation plan, clear team roles, immediate availability of rescue equipment, and multidisciplinary participation are especially important in high-risk neonatal cases.
The second cardiac arrest demonstrates that even a carefully planned fiberoptic technique may provoke bronchospasm and rapid cardiovascular collapse in a vulnerable premature infant.
Clear documentation of a difficult airway is essential so that future clinicians can anticipate the problem and prepare an appropriate strategy.
This single case supports fiberoptic intubation through a laryngeal mask as a useful rescue and definitive technique, but it does not establish its superiority over other advanced pediatric airway strategies.
Thank you to Cureus for allowing us to summarize this article.