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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 144-147

C-MAC® videolaryngoscope in difficult paediatric airway: Need to update our perspective

Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India

Date of Submission03-Oct-2020
Date of Acceptance07-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Sarabjeet Chhabra
Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_44_20

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Difficult airway in the paediatric population poses a serious obstacle for tracheal intubation leading to grave consequences. Direct laryngoscopy may often not yield an ideal view for intubation, and the aid of supraglottic airway device, videolaryngoscope (VLS) and/or fibreoptic devices may be sought. We discuss the benefit of using C-MAC® VLS-guided technique for difficult intubation in a child. We also suggest that videolaryngoscopy be considered a standard approach in paediatric intubations where such facilities are available.

Keywords: C-MAC®, difficult intubation, paediatric intubation, videolaryngoscope

How to cite this article:
Mundotiya S, Palta S, Saroa R, Chhabra S. C-MAC® videolaryngoscope in difficult paediatric airway: Need to update our perspective. Airway 2020;3:144-7

How to cite this URL:
Mundotiya S, Palta S, Saroa R, Chhabra S. C-MAC® videolaryngoscope in difficult paediatric airway: Need to update our perspective. Airway [serial online] 2020 [cited 2023 Jun 7];3:144-7. Available from: https://www.arwy.org/text.asp?2020/3/3/144/304852

  Introduction Top

Unanticipated difficult airway in the paediatric population has always been a nightmare even for experienced anaesthesiologists due to obligatory differences pertaining to the airway and decreased functional residual capacity that may contribute to rapid desaturation in children. The use of laryngeal mask airway (LMA), videolaryngoscope (VLS) and/or fibreoptic device is recommended as the successive stepwise approach while managing a difficult airway in the paediatric population according to paediatric difficult airway guidelines.[1],[2] Amongst the available VLS, although the use of GlideScope® (GVL: Verathon Medical, Bothell, WA, USA) has been widely reported in paediatric difficult airway, the use of C-MAC® VLS system (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) has been described sparingly.[3] We hereby report the use of the C-MAC VLS to manage an unanticipated difficult airway in a child scheduled to undergo elective orthopaedic procedure under general anaesthesia, and discuss the various modalities available for managing difficult airway in the paediatric population.

  Case Report Top

A 20-month-old boy weighing 8 kg, scheduled to undergo open reduction for bilateral developmental dysplasia of hip under general anaesthesia, presented for preoperative anaesthetic evaluation. Although birth history revealed preterm delivery at 30 weeks of gestation with a history of ventilator support for 72 h, there was no other significant history with normal milestones till date. A history of previous inguinal hernia repair under general anaesthesia was documented as being uneventful, but anaesthetic records were not available. No facial or truncal abnormalities were observed, and haematological and biochemical parameters were within normal limits. The child had mild upper respiratory tract infection for which paediatric consultation and clearance was obtained.

Intravenous (IV) access was secured on the left hand with a 22 SWG cannula. The patient was monitored with continuous electrocardiogram, automated noninvasive blood pressure measurement and pulse oximetry, while inhalational induction was performed with sevoflurane in oxygen using the Jackson-Rees circuit. Atropine (10 μg/kg) and fentanyl (2 μg/kg) were administered intravenously. After confirming the ability to ventilate with face mask, a nondepolarising muscle relaxant (atracurium) was administered to facilitate tracheal intubation. Direct laryngoscopy (DL) was performed using conventional paediatric laryngoscope with size 1 Miller blade, and a Cormack–Lehane (CL) Grade 4 view (epiglottis not visible) was obtained at the first attempt. A second attempt at laryngoscopy performed by an experienced anaesthesiologist after applying backward, upward and rightward pressure (BURP) was also unsuccessful. An attempt to achieve ventilation through a ProSeal® LMA #1.5 as a rescue device failed twice despite apparent correct placement of the same. Bag-mask ventilation was started as soon as the saturation fell below 85%, and also intermittently between attempts until saturation reached >95%. However, the lowest saturation recorded during the multiple attempts at securing a definite airway and bag-mask ventilation ranged between 70% and 75%. In the meanwhile, the help of a senior anaesthesiologist was sought and the C-MAC VLS system was also called for. An otorhinolaryngologist was requested to standby in the event of the need for a surgical airway. A third attempt at DL made with a Macintosh blade with BURP manoeuvre by a senior anaesthesiologist was also unsuccessful. Finally, DL was repeated with C-MAC with Macintosh blade number 3 along with BURP manoeuvre. An improved CL grading was obtained (from Grade 4 to Grade 3b - epiglottis visible but not liftable), though the intubation attempt with 3.5 mm ID endotracheal tube (ETT) with stylet failed. Subsequently, tracheal intubation could be achieved with a styleted 3.5 mm ID ETT in the second attempt after lifting the epiglottis with the tip of the C-MAC blade. A nasogastric tube was placed and injectable dexamethasone was administered in view of repeated attempts at intubation to prevent laryngeal oedema. Anaesthesia was maintained using total IV anaesthesia keeping in mind the rapid recovery of reflexes at extubation. The entire surgical procedure was uneventful.

The child was extubated at the end of the surgical procedure and shifted to the intensive care unit (ICU) for observation where he developed three episodes of grand mal tonic–clonic seizures 4 h post-surgery that were managed by titrated doses of IV benzodiazepines and barbiturates. Non-contrast computerised tomography of the head was found to be normal. Laboratory investigations reported hypocalcaemia which was corrected and no further seizures occurred during his stay in the ICU. The child was discharged after 48 h from the ICU in stable condition. The difficult airway status was documented and provided to the parents for future concerns.

The patient was rescheduled for surgery after 3 months. In view of an anticipated difficult airway, C-MAC VLS system, a paediatric bronchoscope (1.4 mm outer diameter) and a cricothyroidotomy set were kept ready preinduction. Since an IV line was already in situ, IV induction was performed as per institutional protocol. Direct laryngoscopy with C-MAC Macintosh blade 3 with BURP manoeuvre revealed CL Grade 3b. However, intubation was successful only in the second attempt with a styleted 4.0 mm ID ETT. The operative procedure was uneventful and extubation was carried out without any complications.

  Discussion Top

Airway-related complications account for majority of perioperative critical incidents in children during anaesthesia, contributing to significant morbidity and mortality. Although the role of supraglottic airway devices as the primary choice in difficult airway has increased considerably over the last two decades, endotracheal intubation is the definitive approach of securing an airway in major and prolonged surgeries in paediatrics. Direct laryngoscopy with Miller or Macintosh blade is documented to be the gold standard for endotracheal intubation. In addition to the variability of laryngeal anatomy in children and the inability to assess the Mallampati score, intubation in an unanticipated difficult airway in a child using a classic laryngoscope becomes all the more difficult, obligating the need for alternate airway devices such as LMA, VLS and/or fibreoptic device.

The guidelines for unanticipated difficult paediatric airway describe DL as the first approach for intubation while nasal oxygen is being continuously administered, and insertion of LMA on failed attempt.[1],[2] Intermittent bag-mask ventilation with 100% oxygen was done in the present case due to non-availability of paediatric nasal cannula in our resource-limited setup. The use of LMA is often specified in scenarios where intubation has failed. However, LMA did not prove to be beneficial in our patient. We hypothesise that the tip of the LMA probably abutted against the large epiglottis and pushed it onto the glottic inlet, thereby preventing air entry into the trachea. Videolaryngoscopy has been shown to successfully aid in both normal and difficult intubations in children, especially in situations where visualisation of larynx is inadequate, and also in failed cases of DL.[4],[5],[6],[7]

The first-pass success rates of paediatric endotracheal intubation in emergency situations using VLS were almost similar to that of DL (52%–78%). However, the superiority of VLS is evident in difficult tracheal intubations where the first-pass success rates are as low as 3% with DL.[8],[9] GlideScope and C-MAC VLS are available at our centre. We chose the C-MAC VLS as it uses a special nonacute-angled conventional Macintosh blade as compared to the hyperacute curvature of the GlideScope blade, which makes it relatively easier for an anaesthesiologist to perform DL with the former without the need for a particular learning skill that is necessary for the latter. Furthermore, the time taken to intubate with GlideScope is relatively longer as compared to that of the C-MAC system.[10] Several studies have documented the benefits of using a C-MAC system over DL in paediatrics, with the major advantages being a better glottic view and an improved CL grading.[2],[3],[4],[5],[6] Although the use of C-MAC has been documented in children over 2 years of age,[11] the present case demonstrates its usefulness in young children as well.

As per the current practice guidelines, frequent attempts at DL and/or the insertion of LMA may result in airway trauma especially in children. In view of improved visualisation of laryngeal anatomy, minimal manipulation of the airway and high success rates using C-MAC VLS for tracheal intubation in anticipated and unanticipated difficult paediatric airways, its use proves to be a boon in managing difficult paediatric airways. This has been our experience as well. It is the need of the hour for all anaesthesiologists to use the C-MAC VLS as the primary modality and standard approach in unanticipated and anticipated difficult paediatric airways.


We thank Dr Manpreet Singh (Associate Professor) and Professor Deepak Thapa from the Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India, for their valuable guidance.

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the parents have given their consent for clinical information to be reported in the journal. The parents understand that the name and initials of their child will not be published and due efforts will be made to conceal the child's identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pawar DK, Doctor JR, Raveendra US, Ramesh S, Shetty SR, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth 2016;60:906-14.  Back to cited text no. 1
[PUBMED]  [Full text]  
Black AE, Flynn PER, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth 2015;25:346-62.  Back to cited text no. 2
Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 2012;116:629-36.  Back to cited text no. 3
Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus direct laryngoscope: A meta-analysis of randomized controlled trials. Paediatr Anaesth 2014;24:1056-65.  Back to cited text no. 4
Vlatten A, Aucoin S, Litz S, Macmanus B, Soder C. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the pediatric airway-a randomized clinical trial. Paediatr Anaesth 2009;19:1102-7.  Back to cited text no. 5
Kim JT, Na HS, Bae JY, Kim DW, Kim HS, Kim CS, et al. GlideScope video laryngoscope: A randomized clinical trial in 203 paediatric patients. Br J Anaesth 2008;101:531-4.  Back to cited text no. 6
Fiadjoe JE, Kovatsis P. Videolaryngoscopes in pediatric anesthesia: What's new? Minerva Anestesiol 2014;80:76-82.  Back to cited text no. 7
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: Higher frequency of failed attempts and adverse effects found by video review. Ann Emerg Med 2012;60:251-9.  Back to cited text no. 8
Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: A prospective cohort analysis. Lancet Respir Med 2016;4:37-48.  Back to cited text no. 9
Healy DW, Picton P, Morris M, Turner C. Comparison of the GlideScope, CMAC, Storz DCI with the Macintosh laryngoscope during simulated difficult laryngoscopy: A manikin study. BMC Anesthesiol 2012;12:11.  Back to cited text no. 10
Passi Y, Sathyamoorthy M, Lerman J, Heard C, Marino M. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr of age. Br J Anaesth 2014;113:869-74.  Back to cited text no. 11


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