Management of the challenging pediatric airway

Question 1

The incidence of difficult intubation is

Answer 1

lower in children than adults

Question 2

____ is rarely an option in children

Answer 2

awake intubation

Question 3

Describe pediatric anatomical differences in the patient’s tongue

Answer 3

infant’s tongue is relatively large in proportion to the rest of the oral cavity
this contributes to easy obstruction of the infants airway
oral airway helps to relieve the obstruction

Question 4

Describe the additional anatomical fundamentals of the pediatric airway.

Answer 4

nasal passages are relatively narrow
pronounced salivary secretions
large tonsils & adenoids

Question 5

Describe the position of the larynx of the pediatric patient.

Answer 5

higher (more cephalad) for neonates to 2 year of age
larynx seems more anterior with a more acute angle
C3-C4 (adult is C4-C5)
a straight laryngoscope blade more effectively lifts the tongue from the field of view

Question 6

Describe the epiglottis of the pediatric patient.

Answer 6

adult’s epiglottis is flat & broad with an axis parallel to the trachea
infant’s epiglottis is narrower, omega shaped, and angled away for the axis of the trachea
often obstructs the view of the vocal cords & is more difficult to lift

Question 7

Describe the vocal cords of the pediatric patient.

Answer 7

infant’s vocal cords have a lower (caudad) attachment anteriorly than posteriorly, whereas in the adult the axis of the vocal cords is perpendicular to the trachea
can lead to difficult intubation with the tip of the ETT held up at the anterior portion of the folds

Question 8

Describe the trachea of the pediatric patient.

Answer 8

shorter than adults (infant 4-5 cm- adult 10-12 cm)

Question 9

Describe the subglottic area of the pediatric patient

Answer 9

narrowest portion of a child’s larynx is the cricoid cartilage (until about age 8)
when too large of an ETT is inserted, it may pass through the cords, but may become immediately stuck below the cords (subglottic or cricoid ring region)
funnel vs. elliptical shaped

Question 10

A tight fitting ETT that compresses the tracheal mucosa at the level of the cricoid may cause

Answer 10

edema, reduce the luminal diameter, and result in post-extubation croup

Question 11

Because the subglottic region in the infant is smaller than the adult, the same degree of airway edema results in

Answer 11

greater resistance in the infant

Question 12

Evaluation of the pediatric airway should include

Answer 12

mallampati (mouth opening) and mandible
history of a syndrome/congenital anomalies or physical findings
loose or missing teeth
recent respiratory infections
work of breathing (rate, nasal flaring, accessory muscles, etc.)
snoring/noisy breathing at night
baseline oxygen saturation
asthma/smoking
global appearance

Question 13

Unique anatomic features of the pediatric airway include

Answer 13

prominent occiput, cephalad larynx, & epiglottis angled over vocal cords

Question 14

The most frequent mistake is

Answer 14

late recognition of upper airway obstruction

Question 15

Evidence of airway obstruction includes

Answer 15

tracheal tug, paradoxical chest wall movement, absence of movement in the ambu breathing bag or capnography tracing

Question 16

Inadequate sedation depth may result in

Answer 16

struggle, breath holding, partial airway obstruction, rapid desaturation

Question 17

Overly aggressive bag-mask ventilation can lead to

Answer 17

gastric insufflation, reducing lung volumes, and increased risk of regurgitation

Question 18

The highest incidence of difficult pediatric airway is among the

Answer 18

infant age group, craniofacial anomalies, and congenital cardiac anomalies

Question 19

The _____ correlates with the Cormack-Lehane view

Answer 19

Mallampati

Question 20

The difficult pediatric airway may improve with age, with the exception of certain syndromes such as

Answer 20

Goldenhar & mucopolysaccahardioses the airway becomes more difficult with age

Question 21

To predict a difficult pediatric airway, observe

Answer 21

the child’s profile & look for recessed or smaller than normal mandible, limited mouth opening, prominent dentition, facial asymmetry, and cleft palate

Question 22

Syndromes and conditions associated with a difficult airway include

Answer 22

Goldenhar
Pierre Robin
Treacher Collins
Apert
Trisomy 21
Juvenile arthritis
cleft palate
trauma/burn
oral tumors
Kippel-Feil
mucopolysaccharidosis

Question 23

Preparation for a difficult airway includes:

Answer 23

difficult airway cart: laryngoscope blades, LMAs, tracheal tubes, oral & nasal airways, fiberoptic & video laryngoscope instruments
IV access
experienced assistance
sedation options
Plans A, B, and C
communication with the otolaryngologist and anesthesia providers in advance

Question 24

Induction strategies for the difficult airway include

Answer 24

maintain spontaneous respirations whenever possible- delay positive pressure ventilation and muscle relaxation
a nasopharyngeal airway or small ETT inserted in the nasopharynx can act as an oxygen conduit during intubation attempts
cautious titration with a combo of propofol, ketamine, dexmedetomidine, & midazolam

Question 25

The second most important skill is

Answer 25

direct laryngoscopy (following proper bag-mask ventilation)

Question 26

The ______ _should be considered with direct laryngoscopy

Answer 26

size of the patient’s mandible rather than the age or weight should be considered

Question 27

A _______ will often yield the best view in micrognathic/retrognathic patients

Answer 27

straight blade

Question 28

When performing direct laryngoscopy,

Answer 28

insert on the extreme right
may be helpful to have an assistant pull the back right corner of the child’s mouth
styletted ETT

Question 29

Supraglottic airways are not as useful when

Answer 29

obstruction is beyond the glottis, requirement of high ventilation pressures, and those at risk for pulmonary aspiration

Question 30

Supraglottic airways are not

Answer 30

a secure airway but they are useful as a conduit for fiberoptic tracheal intubation
-often easier to perform once ventilation has been established as successful and then the patient is sedated and paralyzed

Question 31

Since children will desaturate more quickly with apnea, consider

Answer 31

inserting the styletted ETT into the right side of the mouth towards the hypopharynx prior to video laryngoscope insertion
stylet in the shape of the blade vs. a hockey stick configuration

Question 32

When using the flexible fiberoptic scopes, require

Answer 32

adequate oxygenation throughout (i.e. ETT inserted into nasopharynx)
load tracheal tube onto fiberscope with the tip flex anteriorly
hold the scope at the level where its tip will be at the vocal cords

Question 33

For the unanticipated difficult airway, if bag-mask ventilation is easy or the patient is spontaneously breathing

Answer 33

reverse any sedation/muscle relaxation if possible and awaken the child

• do not repeat identical attempts at direct laryngoscopy
• consider an LMA to temporize, improve oxygenation, and to free up the provider’s hands

Question 34

If bag-mask ventilation is not adequate

Answer 34

IMMEDIATLEY request expert help including an otolaryngologist/anesthesia provider/ECMO deployment
2-hand bag-mask attempt–> LMA insertion–> emergency invasive airway access (cricothyroidotomy/rigid bronchoscopy/surgical tracheotomy)

Question 35

Cricothyroidotomy supplies include

Answer 35

a syringe half filled with saline
IV catheter
15-mm adapter from ETT

Question 36

The challenging pediatric airway summary includes

Answer 36

known vs. unexpected
assess previous airway records
ensure pediatric airway adjuncts & pediatric experienced help
light to no sedation before establishing an airway
maintain spontaneous respirations whenever possible
consider fiberoptic intubation through a LMA
“Cannot ventilation, cannot intubate”- immediately establish surgical airway