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Failed insertion of endotracheal tube through classic laryngeal mask airway

A 1-month-old infant, weighing 3.8 kg, had an unanticipated difficult airway with failure to intubate the trachea despite repeated direct laryngoscopic attempts. Adequate ventilation was achieved with cLMA size 1.0. A flexible fiberoptic bronchoscope (FOB; size 2.8) through cLMA showed grade 4 glottic view.[1] It was decided that a size 3.5 uncuffed ETT to be passed over the FOB and tracheal intubation attempted using cLMA as a conduit. Despite successfully negotiating the FOB into the trachea, we were unable to pass the 3.5mm ETT through the cLMA 1.0. Subsequently, tracheal intubation was achieved with a size 3.0-mm ID uncuffed ETT through the same cLMA 1.0 by using the blind technique.