Pediatric Difficult Airway Flashcards
Tongue
Relatively large in proportion to oral cavity
More easily obstructs the airway
Consider an oral airway
Nose
Nasal passages are relatively narrow
Mouth
Pronounced salivary secretions
Tonsils & adenoids more prominent (larger)
Occiput
Prominent
Consider shoulder roll to align axes rather than donut
Neck flexed when in supine position
Upper airway obstruction more common
Larynx
More cephalad (neonate to 2yo)
Anterior w/ acute angle
C3-C4 (adults C4-C5)
Miller or straight blade laryngoscope more effectively lifts the tongue
Epiglottis
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
Vocal Cords
Lower (caudad) attachment anteriorly than posteriorly
Adult vocal cords are perpendicular to the trachea
Trachea
Shorter than adults
Infant 4-5cm
Adult 10-12cm
Subglottic Region
NARROWEST portion in child larynx = cricoid cartilage below the glottic opening (until 8yo)
Funnel vs. elliptical shaped
Anterior/posterior dimension > transverse
Airway edema ↑resistance
Cricoid Cartilage
Only complete cartilage ring in the larynx - not distensible
Airway Evaluation
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
Upper Airway Obstruction S/S
Tracheal tugging
Paradoxical chest wall movement
Absence reservoir bag movement
No ETCO2
Inadequate Sedation S/S
Struggle or breath holding
Partial airway obstruction
Rapid desaturation
What does overly aggressive bag-mask ventilation in pediatric patients lead to?
Gastric insufflation
Reduced lung volumes
↑regurgitation risk
What syndromes & conditions are associated w/ difficult pediatric airway?
Goldenhar Pierre Robin Treacher collins Apert Trisomy 21 Juvenile arthritis Cleft palate Trauma/burns Oral tumors Kippel-Fiel Mucopolysaccharidoses
What syndromes associated w/ predicting difficult pediatric airway become more difficult w/ age?
Goldenhar
Mucopolysaccharidoses
What remains the key to successful airway securement w/ difficult intubations?
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
Supraglottic Airways
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
How to prevent common errors
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
Cricothyroidotomy Supplies
Syringe half-filed w/ saline
IV catheter
15mm ETT adaptor
Flexible Fiberoptic Scope
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
