Airway access using an endotracheal tube changer for safe extubation in an infant with a difficult airway

We present a case where airway access was maintained using an endotracheal tube changer (ETC) after extubation in an infant with a difficult airway. A 4-month-old male infant with bilateral cleft lip and palate, micrognathia, schizencephaly, undescended testis, and abnormality of chromosomes 10 was scheduled for bilateral cleft lip repair. After anesthesia induction with thiamylal and vecuronium, we found that laryngoscopy was difficult (Cormack and Lehane grade III) despite external laryngeal compression. Since there was no fiberoptic bronchoscopy for an infant in our department, and the fact that epiglottis could be visualized with external laryngeal compression, three anesthesiologists attempted tracheal intubation in turn and intubation was successful at last. The surgery was concluded uneventfully; but since endotracheal intubation had been difficult, special care was taken for extubation. We used an ETC for tracheal tube passing into the endotracheal tube at the time of extubation. Although using the ETC in infant with difficult airway for extubation remains controversial, we believe that for a difficult airway, even in an infant, a flexible ETC is a useful device for temporal airway access after extubation.