Management of the Challenging Pediatric Airway

Question 1

infants tongue considerations

Answer 1

infants 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 2

infants nasal passages

Answer 2

relatively narrow

Question 3

infants salivary secretions

Answer 3

pronounced

Question 4

infants tonsils and adenoids

Answer 4

large

Question 5

position of larynx in kids

Answer 5

higher (more cephalic) for neonates 2 years of age. (2 years is usually the age where you can switch to a MAC blade)
larynx seems more anterior with a more acute angle
C3-C4 (adult is C4-C5)
a straight laryngoscope blade more effectively lifts tongue from field of view

Question 6

anatomy of pediatric airway: epiglottis

Answer 6

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

Question 7

anatomy of pediatric airway: vocal cords

Answer 7

infants 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

anatomy of pediatric airway: trachea

Answer 8

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

Question 9

anatomy of pediatric airway: subglottic

Answer 9

narrowest portion of childs larynx is cricoid cartilage (until about 8). in adults it is the glottic opening
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 versus elliptical (football) shaped (anteriors-posterior dimension being greater than the transverse dimension)

Question 10

a tight fitting ETT that depresses the tracheal mucosa can

Answer 10

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

Question 11

evaluation of the airway includes

Answer 11

mallampati and mandible
hx of syndrome/congential anomalies or physical findings
missing or loose teeth
recent respiratory infections
work of breathing
snoring/noisy breathing at night
baseline SpO2
asthma/smoking
global appearance

Question 12

anatomic feature: prominent occiput (big head)
implications
management

Answer 12

implications: neck flexed in supine position, upper aw obstruction likely, Oral/pharyngeal/laryngeal axes are not lined up, making laryngoscopy more difficult
shoulder roll for infants

Question 13

anatomic feature: cephalic larynx
implication
management

Answer 13

larynx seems more anterior
entire tongue is in oral cavity, increasing risk of obstruction
managment: lateral approach to laryngoscopy, oral aw to relieve obstruction

Question 14

anatomical feature: epiglottis angled over vocal cords
implication
management

Answer 14

epiglottis often obstructs view of vocal cords

straight laryngoscope blade in children under 3 years of age

Question 15

evidence of aw obstruction includes

Answer 15

tracheal tug, paradoxical chest wall movement, absence of movement in ambu breathing bag or capnography tracing.
most frequent mistake is late recognition of upper airway obstruction

Question 16

evidence of inadequate sedation depth

Answer 16

struggle, breath holding, partial aw obstruction, rapid desaturation

Question 17

evidence of overly aggressive bag mask ventilation

Answer 17

leads to gastric insufflation, reducing lung volume, increased risk of regurgitation

Question 18

highest difficult aw predictors include

Answer 18

highest in infant age group, craniofacial abnormalities, congenital cardiac abnormalities

Question 19

difficult airway may improve with age except in these syndromes

Answer 19

goldenhar and mucopolysaccharidoses the airway becomes difficult with age

Question 20

mallampati correlates with

Answer 20

cormack-lehane view

Question 21

when observing childs profile, look for

Answer 21

smaller than normal or recessed mandible, limited mouth opening, prominent dentition, facial asymmetry, cleft palate

Question 22

syndromes and conditions associated with a difficult airway

Answer 22

goldenhar
pierre robin
treacher collins
apert
trisomy 21
juvenile arthritis
cleft palate
trauma/burrn
oral tumors
kipper-feil
mucopolysacc haridosis

Question 23

preparation for difficult airway

Answer 23

difficult aw card (laryngoscope blades, LMA’s, tracheal tubes, oral and nasal airways, fiberoptic and video laryngoscope instruments)
IV access
experienced assistance
sedation options
plans A, B, C
communication with otolaryngologist and anesthesia providers in advance

Question 24

induction strategies include

Answer 24

maintain spontaneous respirations whenever possible
delay PPV and NDMB’s especially in mediastinal tumors, epiglottis, foreign body, limited mouth opening
a nasopharyngeal airway or small ETT inserted in nasopharynx can act as oxygen conduit during intubation attempts
cautious titration with combination of propofol, ketamine, dexmedetomidine, midazolam

Question 25

direct laryngoscopy with straight blade

Answer 25

will often yield best view in micrognathic/retrognathic patients
insert on extreme right
may be helpful to have assistant pull back right corner of childs mouth
styletted ETT (careful to not advance through vocal cords to avoid damage to trachea with stiff end of stylet)

Question 26

supraglottic airways when obstruction is beyond glottis

Answer 26

not as useful. requirement of high ventilation pressure and those at risk for pulmonary aspiration

Question 27

supraglottic airways and FOI

Answer 27

useful as conduit for FOI. often easier to perform once ventilation has been established as successful and then patient is sedated or paralyzed

Question 28

how to utilize video laryngoscope

Answer 28

since children will desaturate more quickly with apnea, consider inserting styletted ETT into the right of the mouth towards hypo pharynx prior to video laryngoscope insertion. stylet in the shape of the blade. insertion technique is midline. may also be used with flexible FOI

Question 29

flexible fiberoptic scope how to utilizr

Answer 29

adequate oxygenation throughout
hold the scope at the level where its tip will be at the vocal cords (roughly the angle of the mandible). index finger and thumb grasp the scope at the point where the fingers touch the patient lips/nose
direct the scope midline with anterior flexion at the tip

Question 30

the unanticipated difficult airway and if bag mask ventilation is easy or the patient is spontaneously breathing

Answer 30

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 free up providers hands

Question 31

the unanticipated difficult airway and if bag mask ventilation is not adequate

Answer 31

immediately request expert help including otolaryngologist, anesthesia provider, ECMO deployment
2 hand bag mask attempt->LMA insertion->emergency invasive airway access (cricothyroidotomy/rigid bronchoscopy/surgical tracheostomy)
LMA for free hands+call for help

Question 32

cricothyroidotomy supplies

Answer 32

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

Question 33

difficult airway, unexpected- sequence of events

Answer 33

increase O2 to 100%, call for help, surgical aw expert and cart, bronchoscopy and tracheostomy kit
if unable to mask ventilate, ask for 2 handed assistance and insert OPA/NPA, if unsuccessful, insert supraglottic aw, decompress stomach with OGT, consider reversing with sugammadex
if able to re establish spontaneous ventilation, consider awakening patient
agter two attempts, change provider and consider alternative approaches
if macroglossie, or mediastinal mass, consider prone or lateral position
if still unable to ventilate: younger children: emergency non invasive airway such as rigid bronchoscopy.
in older children: jet ventilation or emergenvy/invasive surgical airway such as cricothyroitomy or tracheostomy

Question 34

alternative approaches for intubation

Answer 34

different blade
reposition head
different provider
video laryngoscope
bougie
intubating LMA
fiberoptic scope
intubating stylet
blind oral
blind nasal