Pediatric Airway (Fundamentals + Difficult Airway)

Question 1

What are the fundamentals of the pediatric airway? (5)

Answer 1

-infant tongue is relatively larger in production to the rest of the oral cavity (can easily obstruct)
-nasal passages are relatively narrow
-pronounced salivary secretions
-large tonsils and adenoids
-prominent occiput

Question 2

Describe the position of the larynx in pediatrics compared to adults

Answer 2

larynx is higher (more cephalad) in neonates to 2 years of age
larynx is more anterior with a more acute angle
C3-C4 (adult C5-6)

Question 3

What blade is more effective in neonates and why?

Answer 3

a straight laryngoscope blade is more effectively lifting the tongue from the field of view

Question 4

Describe the epiglottis in pediatrics compared to adults

Answer 4

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 the view of the vocal cords and is more difficult to lift

Question 5

Describe the vocal cords in pediatrics compared to adults

Answer 5

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 6

Describe the trachea in pediatrics compared to adults

Answer 6

shorter then adults
infants- 4-5cm
adults 10-12cm

Question 7

Describe the subglottic opening in pediatrics compared to adults

Answer 7

narrowest portion of the child’s larynx is the cricoid cartilage (until about age 8)
funnel vs elliptical shaped (anterior posterior dimension being greater than the transverse dimension)

Question 8

What is the narrowest portion of the adult airway?

Answer 8

glottic opening

Question 9

What is the cricoid cartilage?

Answer 9

the only complete ring in the larynx and is not distensible

Question 10

What does a tight fitting ETT do to the tracheal mucosa?

Answer 10

if too tight can cause edema, reduce luminal diameter and result in post-extubation croup

Question 11

Describe the relationship between edema and resistance in an infant

Answer 11

the subglottic region is smaller in the adult the same degree of airway edema results in greater resistance in the infant

Question 12

What are ways to evaluate the airway? (9)

Answer 12

mallampati (mouth opening) and manidble
history of syndrome/congenital anomalities or physical findings
loose or missing teeth
recent respiratory infections
work of breathing (rate, nasal flaring, accessory muscles)
snoring/nosy breathing at night
baseline oxygen saturation
asthma/smoking
global apperance

Question 13

What are the unique anatomic features of the pediatric airway?

Answer 13

prominent occiput
cephalad larynx
epiglottis angled over the vocal cords

Question 14

What are the anesthesia implications and management of the prominent occiput?

Answer 14

neck flexed in supine position, upper airway obstruction likely, oral pharyngeal/laryngeal axes are not lined up, making laryngoscopy difficult
shoulder roll for infants

Question 15

What are the anesthesia implications and management of the cephalad larynx?

Answer 15

larynx seems more anterion, entire tongue is in oral cavity increasing risk of obstruction
laterial approach to laryngoscopy, oral airway to relieve obstruction

Question 16

What are the anesthesia implications and management of the epiglottis angled over the vocal cords?

Answer 16

epiglottis often obstructs the view of vocal cords
straight laryngoscope blade in children under 3 years of age

Question 17

What is the most frequent mistake in the physiological and emotional characteristics of pediatrics?

Answer 17

late recognition of upper airway obstruction

Question 18

What are signs of upper airway obstruction?

Answer 18

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

Question 19

What are common mistakes seen in pediatric airway management?

Answer 19

inadequate sedation depth
overly aggressive bag mask ventilation

Question 20

What are consequences of inadequate sedation depth?

Answer 20

struggling, breath holding, partial airway obstruction, rapid desaturation

Question 21

What are consequences of overly aggressive bag mask ventilation?

Answer 21

leads to gastric insufflation, reducing volumes, and increased risk of regurgitation

Question 22

What are indicators of difficult airway in the pediatric patient?

Answer 22

occurs in infant age group
craniofacial anomalies
congenital cardiac anomalies

Question 23

What correlates with cormack-lehane view?

Answer 23

mallampati score

Question 24

What should be observed during the child’s airway exam?

Answer 24

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

Question 25

Name the syndrome and conditions associated with difficult airways

Answer 25

CHARGE
Trisomy 21/Down syndrome
Hunter and Hurler Sydrome
Cleft Palates
Goldenhar
Pierre Robin
Treacher Collins
Apert
Juvenille Arthritis
trauma/burns
oral tumors
kippel-feil
muccopolysac haridosis

Question 26

What are induction strategies for the difficult airway patient?

Answer 26

maintain spontaneous respirations whenever possible
Delay positive pressure ventilation and muscle relaxation (mediastinal tumors, epiglottis, foreign body, limited mouth opening)
a nasopharyngeal airway or small ETT inserted in the nasopharynx can act as an oxygen conduit during intubation attemps
cautious titration with a combination of propofol, ketamine, dexmedetomidine, midazolam

Question 27

What is KEY?

Answer 27

POSITIONING
lining up the axis,
laryngeal pharyngeal and oral axes

Question 28

What should be considered when choosing an blade size?

Answer 28

size of the patient’s mandible rather then the age or weight

Question 29

What blade is best for micrognathic/ retrognathic patients

Answer 29

straight blade

Question 30

How do you insert your blade?

Answer 30

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

Question 31

When is a LMA no useful?

Answer 31

when the obstruction is beyond the glottis
requirement of high ventilation pressures
patients at risk for pulmonary aspiration

Question 32

How do you insert a video laryngoscope?

Answer 32

insertion technique is midline

Question 33

What do you do in the unanticipated difficult airway?

Answer 33

act quickly and calmly and solicit experienced help
if BMV is easy, reverse and wake child up
if not able to BMV, immediately request expert hepl including ENT, anesthesia provider or ECMO depolyment
2 hand mask, LMA insertion, emergency invasive airway access
(cricothyroidotomy, rigid bronchoscopy, surgical tracheostomy)

Question 34

What supplies is needed for a surgical cric?

Answer 34

syringe 1/2 filled with saline
IV catheter
15mm adapter from ETT

Question 35

Describe the eight steps of an unexpected difficult airway

Answer 35

increase O2 to 100% and maintain continuous O2 flow during airway management
call for help, surgical airway expert
if unable to BMV, ask for two handed assistance and insert oral airway/ nasal airway/ LMA, decompress stomach with OG tube and reverse
if SV: awake and reverse
after two attempts to BMV: change providers and consider alternative approaches to intubation
if macroglossia or mediastinal mass- consider prone or lateral
unable to ventilate: emergency noninvasive airway (rigid bronchoscope)
older: Jet ventilation or emergency invasive surgical airway (cric or trach)

Question 36

What are alternative approaches to intubation?

Answer 36

different blade
re-position head
different provider
video laryngoscope
bougie
intubating LMA
fiberoptic scope
intubating stylet
blind oral
blind nasal

Question 37

What are challenging pediatric airway PEARLS (7)

Answer 37

known vs unknown
assess previous airway records
ensure pediatric airway adjuncts and pediatric experienced help
light to no sedation before establishing an airway
light to no sedation before establishing an airway
maintain spontaneous respirations whenever possible
consider fiberoptic intubation through an LMA
cannot ventilation cannot intubate (immediately establish a surgical airway)

Question 38

what are the most common errors noted in malpractice

Answer 38

lack of equipment in inappropriately size equipment
inadequate skilled help
failure or delay in calling for help
failure to attempt cricothyrotomy soon enough