自發呼吸狀況下以光纖內視鏡穿過喉頭罩為導引進行氣管插管（Treacher Collins Syndrome患者之病例報告）

Fiberoptic Tracheal Intubation through a Classicial Laryngeal Mask Airway under Spontaneous Ventilation in a Child with Treacher Collins Syndrome

困難插管是麻醉醫師的惡夢，而Treacher Collins Syndrome（TCS）患者之氣道維持更是其中極為困難之挑戰，在此我們報告一例進行上顎修補之TCS患者麻醉的經驗。病患除小頭症外同時合併睡眠呼吸中止、慢性肺疾、動脈導管及卵圓窗閉鎖不全以及尿布疹等。第一次麻醉以傳統方式進行，雖經過積極努力，但均無法順利插入氣管內管；之後在喉頭罩輔助下勉強維持換氣及血氧飽和度在90％，待病患甦醒後，開刀暫延；一個月後，以分段方式逐步給予propofol進行麻醉誘導，總共每公斤2毫克時睫毛反射消失，在病患自發呼吸狀況下，先插入2號喉頭罩，然後再以直徑2.5公釐的軟式光纖內視鏡套上內徑4公釐氣管內管，由喉頭罩伸入氣管，其後並以內視鏡為導引，插入內徑4公釐氣管內管，在移除內視鏡後，則用另支同碼之氣管內管協助推送移出喉頭罩，整個過程均在病患自發呼吸狀況下順利完成，並可維持優良換氣避免病患缺氧。在小兒氣道維持有困難時，以靜脈注射propofol麻醉並維持病患自發呼吸狀況下，結合軟式光纖內視鏡及喉頭罩進行氣管內管插入，並以另支同碼之氣管內管協助推送移出喉頭罩，可全程維持通暢呼吸道，為面對小兒困難插管時，安全且簡易的選擇。

This report cites the usefulness of fiberoptic scope-guided endotracheal tube intubation through a classical laryngeal mask airway (LMA) during spontaneous breathing. Treacher Collins Syndrome (TCS) is a condition where airway management is stressful to anesthesiologists. We report a pediatric patient with TCS undergoing cleft palate repair. The patient had a history of sleep apnea syndrome, chronic lung disease, and congenital heart disease. Intubation by rigid laryngoscopy was unsuccessful at the first attempt. One month later, under spontaneous ventilation, tracheal intubation was smoothly performed with the use of a fiberoptic scope through an LMA under intravenous anesthesia with propofol. Fiberoptic scope-guided endotracheal intubation through an LMA with the push of another ETT of the same size to curb the back slippage of the endotracheal tube already inserted in the trachea can be easily and safely performed under spontaneous breathing in a pediatric patient with TCS.