Comparison of Spontaneous Breathing Versus Paralyzed Technique During Flexible Bronchoscopic Intubation in Anesthetized Children and Adolescents With Temporomandibular Joint Ankylosis: Randomized Parallel Group Trial.

Background: Literature is sparse on airway management in temporomandibular joint ankylosis patients, and it is not known whether spontaneous or paralyzed technique of intubation will be better for flexible bronchoscopic intubation.

Aim: To compare the incidence of difficult flexible bronchoscopic intubation between the spontaneously breathing and paralyzed groups in anesthetized children and adolescents.

Methods: In this Randomized parallel group study, after ethics committee approval and trial registration, we enrolled 70 children and adolescents up to 18 years with temporomandibular joint ankylosis and mouth opening < 1.5 cm scheduled for elective surgery after informed written consent from the parents. Patients were randomized into anesthetized spontaneous breathing (group S) and paralyzed (group P) groups. The primary objective was the incidence of difficult flexible bronchoscopic intubation. Secondary outcomes were time to glottis, carina, time required for intubation, desaturation, coughing/movement, and hemodynamics during intubation and postoperative sore throat. Data were analyzed in SPSS version 29.

Results: Baseline and demographic data were comparable. The paralyzed group had a significantly lower incidence of difficult flexible bronchoscopic intubation [group P versus group S: 1 (2.86%) vs. 18 (51.42%), p < 0.001; RR (95% CI): 0.06 (0.01-0.39)], lower time to visualize the glottis [Median difference 30 (24, 36) sec, p < 0.001], lower time to the carina [Median difference 62 (29, 94) sec; p = 0.001], lower time to intubation [Median difference 97 (59, 135) sec, p = 0.003], lower incidence of vocal cord closure [-20% (-33.3% to -6.7%); p = 0.005], lower incidence of blood in the bronchoscopy field [-28.6% (-44.9% to -12.2%); p = 0.002], and lower incidence of desaturation [-14.3% (-27.9% to -0.63%); p = 0.04] compared to the spontaneous group. Coughing, hemodynamic response to intubation, and postoperative sore throat were comparable between the groups.

Conclusion: Paralyzed technique is associated with lower incidence of difficult flexible bronchoscopic intubation compared to spontaneously breathing technique in children and adolescents with temporomandibular joint ankylosis.

Trial registration: CTRI/2022/03/041362.