Securing a difficult airway

15month old 8kg weighing with bil TM joint ankylosis with moth closed completely.
what options are available to securing airway electively

1. be quiet and always have another colleague next to you. 
2. have a skilled ENT pediatric surgeon aside and prepped 
3. pediatric difficult airway cart in and ready 
4. volatile induction and spontaneous breathing. 
5. mask ventilation (SEV) and secure an i.v. 
6. nasal topical anesthesia (a few drops of 2% esracaine would be ok). 
7. CRITICAL: when inserting the FOB do it through a dedicated face mask with a special FOB port. While one nostril is obstructed by the FOB, you can hand ventilate the child through the second. In fact it may be best to deepen the child this way w/o paralyzing. Keep the tip of the FOB above the vocal cords. Thus you can ventilate w/o obstructing the larynx. 
8. the ETT must fit both the FOB and the airway (sorry for writing this stupid point but it's like a check list. never let anything unchecked). Also: warmed in water and well lubricated. 
9. start advancing the ETT. Some gentle rotation left-right may help especially at the nose-nasopharynx curve. 
10. once the tip of the ETT is beyond the tip of the FOB (t.i. you see it) keep the ETT still, advance the FOB between the vocal cords, or gently advance them both.advance the ETT until you see it again. then retract the FOB while keeping the ETT in position. 
11. Well, you're almost done. Don't forget that the narrowest part of the airway is still below the vocal cords in this age group. 
12. Check double lung ventilation. 
13. Fixation, listen again. 
14. If you're happy proceed. If in doubt stop and reassess. You're elective! 
15. Have drugs ready in case of laryngo/bronchospasm. 
Good luck


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