FETAL (Fetus Establish Tracheal Access for Lifeguard) as a Complementary Maneuver for Tracheal Deviation Secondary to Complications of Pulmonary Sequestration: Case Report and Technical Description

Introduction: Bronchopulmonary sequestration (BPS) is a congenital pulmonary malformation that, in severe cases, can lead to fetal hemodynamic compromise, hydrothorax, mediastinal shift, and an increased risk of neonatal airway obstruction. Objective ultrasound-based parameters such as the congenital pulmonary airway malformation volume ratio (CVR), mediastinal shift, and the tracheoesophageal displacement index (TEDI) have been proposed as key predictors of perinatal complications. The EXIT (Ex Utero Intrapartum Treatment) procedure enables secure airway management in neonates at risk of severe obstruction. Case Presentation: We report the case of a 27-year-old pregnant patient at 29 weeks gestation diagnosed with left extra lobar BPS, with a CVR of 1.7, associated hydrothorax, and mediastinal shift. The fetus underwent laser ablation of the feeding vessel and thoracoamniotic shunting, with improvement in ultrasound parameters. At 36 weeks, persistent residual hydrothorax and a TEDI of 16 were documented, prompting a planned EXIT procedure. An endoscopic-guided intubation technique, termed FETAL (Fetus Establish Tracheal Access for Lifeguard), was developed and successfully employed for airway access. The neonate underwent definitive postnatal surgical resection with favorable postoperative recovery. Discussion: This case illustrates the importance of a stepwise management strategy guided by objective sonographic predictors. An initially elevated CVR supported the indication for fetal intervention with laser ablation and thoracoamniotic shunting. The persistence of hydrothorax and a high TEDI score subsequently indicated the need for advanced airway management via EXIT. The FETAL technique, developed by our team, enabled guided endoscopic intubation with direct visualization, reducing the risk of inadvertent esophageal intubation. This sequence of clinical decisions reflects a personalized, multidisciplinary and evidence-based approach. Conclusion: A structured strategy allowed timely intervention at each stage of fetal management, optimizing the perinatal outcome. The FETAL technique represents a safe and effective alternative for fetal airway management during EXIT in selected cases at high risk of tracheal obstruction.