Pediatric Difficult Airway

Question 1

Tongue

Answer 1

Relatively large in proportion to oral cavity
More easily obstructs the airway
Consider an oral airway

Question 2

Nose

Answer 2

Nasal passages are relatively narrow

Question 3

Mouth

Answer 3

Pronounced salivary secretions

Tonsils & adenoids more prominent (larger)

Question 4

Occiput

Answer 4

Prominent
Consider shoulder roll to align axes rather than donut
Neck flexed when in supine position
Upper airway obstruction more common

Question 5

Larynx

Answer 5

More cephalad (neonate to 2yo)
Anterior w/ acute angle
C3-C4 (adults C4-C5)
Miller or straight blade laryngoscope more effectively lifts the tongue

Question 6

Epiglottis

Answer 6

Narrow omega shape Ω
Angled away from the trachea axis
Often obstructs the vocal cord view and more difficult to lift
Consider straight blade in children < 3yo

Question 7

Vocal Cords

Answer 7

Lower (caudad) attachment anteriorly than posteriorly

Adult vocal cords are perpendicular to the trachea

Question 8

Trachea

Answer 8

Shorter than adults
Infant 4-5cm
Adult 10-12cm

Question 9

Subglottic Region

Answer 9

NARROWEST portion in child larynx = cricoid cartilage below the glottic opening (until 8yo)
Funnel vs. elliptical shaped
Anterior/posterior dimension > transverse
Airway edema ↑resistance

Question 10

Cricoid Cartilage

Answer 10

Only complete cartilage ring in the larynx - not distensible

Question 11

Airway Evaluation

Answer 11

Mallampati
Mouth opening
Syndrome or congenital anomalies
Loose or missing teeth
*Recent respiratory infections
WOB
Snoring or noisy breathing at night
Baseline oxygen saturation
Asthma
2nd hand smoke
Teenagers recreational drugs or smoke

Question 12

Upper Airway Obstruction S/S

Answer 12

Tracheal tugging
Paradoxical chest wall movement
Absence reservoir bag movement
No ETCO2

Question 13

Inadequate Sedation S/S

Answer 13

Struggle or breath holding
Partial airway obstruction
Rapid desaturation

Question 14

What does overly aggressive bag-mask ventilation in pediatric patients lead to?

Answer 14

Gastric insufflation
Reduced lung volumes
↑regurgitation risk

Question 15

What syndromes & conditions are associated w/ difficult pediatric airway?

Answer 15

Goldenhar
Pierre Robin
Treacher collins
Apert
Trisomy 21
Juvenile arthritis
Cleft palate
Trauma/burns
Oral tumors
Kippel-Fiel
Mucopolysaccharidoses

Question 16

What syndromes associated w/ predicting difficult pediatric airway become more difficult w/ age?

Answer 16

Goldenhar

Mucopolysaccharidoses

Question 17

What remains the key to successful airway securement w/ difficult intubations?

Answer 17

POSITIONING
Sniffing position
- Shoulder roll
- Headrest
- Ensure neck wide & open
- Horizontal alignment b/w glabella & chin plane as well as external auditory meatus & suprasternal notch

Question 18

Supraglottic Airways

Answer 18

LMA = let me aspirate → NOT a secure airway
*Not useful when the obstruction lies beyond the glottis, high ventilation pressures are requires, or patients at pulmonary aspiration risk
Used as conduit for fiberoptic tracheal intubation

Question 19

How to prevent common errors

Answer 19

Be prepared - appropriate equipment + up/down sizes
Assess previous airway records
Ensure pediatric airway adjuncts available
Limit sedation before establishing an airway
Keep ‘em breathing → maintain spontaneous respirations when possible
Consider fiberoptic intubation
Cannot ventilate, cannot intubate → immediately establish surgical airway
Experienced, skilled pediatric airway provider available
CALL FOR HELP

Question 20

Cricothyroidotomy Supplies

Answer 20

Syringe half-filed w/ saline
IV catheter
15mm ETT adaptor

Question 21

Flexible Fiberoptic Scope

Answer 21

Combination use w/ other airway devices
Oxygenate throughout (ETT inserted into nasopharynx)
Load tracheal tube onto fiberscope w/ tip flexed anteriorly
Bed in lowest position to ensure fiberoptic scope remains straight
Hold scope at level where the tip lies at the vocal cords (mandible angle)
Index finger & thumb grasp scope where the fingers touch the patient lips/nose
Direct the scope midline w/ anterior flexion at the tip