Technique for Consistent Selective Left Mainstem Intubation in Neonatal and Infantile Surgery

Abstract

Selective left mainstem intubation can be challenging in neonates and infants due to airway fragility, limited device options, and the natural inclination toward right-sided placement. This paper describes a sample case series demonstrating a technique that combines patient positioning, a Seldinger-like approach using a soft stylet, and real-time fluoroscopic guidance for optimal left mainstem intubation. The method has become an institutional standard for procedures requiring single-lung ventilation, including esophageal atresia with tracheoesophageal fistula repair and congenital pulmonary airway malformation surgeries. Fluoroscopic imaging offers objective confirmation of tube placement, while reducing airway trauma and need for advanced bronchoscopy. Our experience indicates that reliance on auscultation alone can be minimized, leading to quicker, more precise verification of left mainstem intubation with minimal excess radiation. No technique-specific complications have been observed. Thus, this method provides a reliable alternative for achieving selective left mainstem intubation in pediatric populations, offering improved safety and procedural efficiency.