Management of the challenging pediatric airway Flashcards
The incidence of difficult intubation is
lower in children than adults
____ is rarely an option in children
awake intubation
Describe pediatric anatomical differences in the patient’s tongue
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
Describe the additional anatomical fundamentals of the pediatric airway.
nasal passages are relatively narrow
pronounced salivary secretions
large tonsils & adenoids
Describe the position of the larynx of the pediatric patient.
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
Describe the epiglottis of the pediatric patient.
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
Describe the vocal cords of the pediatric patient.
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
Describe the trachea of the pediatric patient.
shorter than adults (infant 4-5 cm- adult 10-12 cm)
Describe the subglottic area of the pediatric patient
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
A tight fitting ETT that compresses the tracheal mucosa at the level of the cricoid may cause
edema, reduce the luminal diameter, and result in post-extubation croup
Because the subglottic region in the infant is smaller than the adult, the same degree of airway edema results in
greater resistance in the infant
Evaluation of the pediatric airway should include
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
Unique anatomic features of the pediatric airway include
prominent occiput, cephalad larynx, & epiglottis angled over vocal cords
The most frequent mistake is
late recognition of upper airway obstruction
Evidence of airway obstruction includes
tracheal tug, paradoxical chest wall movement, absence of movement in the ambu breathing bag or capnography tracing
Inadequate sedation depth may result in
struggle, breath holding, partial airway obstruction, rapid desaturation
Overly aggressive bag-mask ventilation can lead to
gastric insufflation, reducing lung volumes, and increased risk of regurgitation
The highest incidence of difficult pediatric airway is among the
infant age group, craniofacial anomalies, and congenital cardiac anomalies
The _____ correlates with the Cormack-Lehane view
Mallampati
The difficult pediatric airway may improve with age, with the exception of certain syndromes such as
Goldenhar & mucopolysaccahardioses the airway becomes more difficult with age
To predict a difficult pediatric airway, observe
the child’s profile & look for recessed or smaller than normal mandible, limited mouth opening, prominent dentition, facial asymmetry, and cleft palate
Syndromes and conditions associated with a difficult airway include
Goldenhar Pierre Robin Treacher Collins Apert Trisomy 21 Juvenile arthritis cleft palate trauma/burn oral tumors Kippel-Feil mucopolysaccharidosis
Preparation for a difficult airway includes:
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
Induction strategies for the difficult airway include
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
The second most important skill is
direct laryngoscopy (following proper bag-mask ventilation)
The ______ _should be considered with direct laryngoscopy
size of the patient’s mandible rather than the age or weight should be considered
A _______ will often yield the best view in micrognathic/retrognathic patients
straight blade
When performing direct laryngoscopy,
insert on the extreme right
may be helpful to have an assistant pull the back right corner of the child’s mouth
styletted ETT
Supraglottic airways are not as useful when
obstruction is beyond the glottis, requirement of high ventilation pressures, and those at risk for pulmonary aspiration
Supraglottic airways are not
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
Since children will desaturate more quickly with apnea, consider
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
When using the flexible fiberoptic scopes, require
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
For the unanticipated difficult airway, if bag-mask ventilation is easy or the patient is spontaneously breathing
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
If bag-mask ventilation is not adequate
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)
Cricothyroidotomy supplies include
a syringe half filled with saline
IV catheter
15-mm adapter from ETT
The challenging pediatric airway summary includes
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
