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PRESTO vs. EXIT for the Management of Prenatally Anticipated Difficult Airway: Techniques and Outcomes
Abstract Number: T2H-370
Abstract Type: Original Research
Background: Anticipated neonatal difficult airway can be an indication for birth via Ex-Utero Intrapartum Treatment (EXIT) procedure. However, the EXIT procedure confers additional maternal operative risk. An alternative strategy is a Procedure Requiring Second Team in the OR (PRESTO) where the fetus is delivered by scheduled cesarean delivery and the potentially difficult airway is managed by a multidisciplinary resuscitation team including surgeons, neonatologists, anesthesiologists, nurses, and respiratory therapists. We present airway management techniques and outcomes of 38 patients at a single quaternary care center from 2009-2017 who presented with prenatally anticipated neonatal difficult airways based on prenatal imaging.
Methods: Retrospective chart review of fetuses with prenatally anticipated neonatal difficult airway evaluated at a single institution from 2009-2017 was performed. Operative notes, resuscitation records, anesthesia records, progress notes, prenatal diagnosis and imaging, and maternal blood transfusion rates were reviewed.
Results: 38 patients met inclusion criteria. 16 were managed by PRESTO and 22 by EXIT. Subjects managed by PRESTO had micrognathia due to craniofacial syndromes (n=9), or smaller or less invasive neck masses (n=7). Subjects managed by EXIT had large cervical lymphangiomas (n=7), teratomas (n=10), cystic masses (n=2), epulis (n=2) or goiter (n=1). Gestational age at delivery was 37.4 weeks for PRESTO vs. 36.4 weeks for EXIT (p=0.08). Four of the PRESTO cases did not require neonatal airway intervention. Of the 12 PRESTO cases where the neonate was intubated, 6 were intubated with a fiberoptic scope through a laryngeal mask airway, 3 with a rigid bronchoscope, and 3 by direct laryngoscopy. Of the 22 EXIT patients, management was widely varied according to the underlying pathology and included interventions such as cyst drainage or mass resection. Airway techniques ranged from direct laryngoscopy to retrograde intubation or tracheostomy. One mother experienced placental abruption during EXIT procedure, requiring transfusion of 2 units of packed red blood cells, whereas there were no intraoperative maternal complications in the PRESTO cohort.
Conclusions: The potential benefit to the fetus of placental bypass during EXIT procedure must be weighed against the increased maternal risks of transfusion as well as recommendations to wait for 2 years for a subsequent pregnancy and to deliver by cesarean during future pregnancies. PRESTO is associated with decreased maternal operative morbidity and vaginal birth after cesarean is typically a delivery option during future pregnancies. However, PRESTO should only be offered in centers that have the capacity to assemble an expert multidisciplinary airway management team on short notice, including on nights and weekends.