Difficult airway management: children are different from adults, and neonates are different from children!

Abstract

Children are different from adults in many aspects of airway management. For example, it is generally believed that the incidence of unexpected difficult airway management in children is low, and that most children who have difficult to manage airways can be identified in advance.1Black A.E. Flynn P.E. Smith H.L. Thomas M.L. Wilkinson K.A. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice.Paediatr Anaesth. 2015; 25: 346-362Crossref PubMed Scopus (94) Google Scholar In this issue of the British Journal of Anaesthesia, Disma and colleagues2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar report that neonates (and infants) are also quite different from older children when it comes to difficult airway management. Disma and colleagues2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar present an analysis of difficult tracheal intubation in neonates and infants derived from a European multicentre observational cohort study of critical events in paediatric anaesthesia (the NEonate-Children sTudy of Anaesthesia pRactice IN Europe [NECTARINE] study).3Disma N. Veyckemans F. Virag K. Kaufmann J. et al.Morbidity and mortality following anaesthesia in early life: results of the European prospective multicentre observational study, NECTARINE.Br J Anaesth. 2021 Mar 31; (S0007-0912(21)00111-2; Online ahead of print. PMID: 33812668)https://doi.org/10.1016/j.bja.2021.02.016Abstract Full Text Full Text PDF Scopus (27) Google Scholar Neonates and infants up to 60 weeks postconceptual age undergoing anaesthesia for surgical and non-surgical procedures were recruited during a 3-month period between March 2016 and January 2017. The resulting cohort is perhaps the best available snapshot of difficult airway management in the youngest patient populations. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred at an incidence of 5.8% (95% confidence interval 5.1–6.5%). In two-thirds of those patients, difficult intubation was unexpected. The most frequent interventions used to achieve a successful tracheal intubation were changing the laryngoscope blade and calling for experienced help. Advanced alternative indirect techniques such as use of a videolaryngoscope or fibreoptic bronchoscope were only utilised in a limited number of cases where difficult intubation was expected. Successful intubation was achieved in 98% of cases within an average of three attempts, with no patients requiring a surgical airway. Bradycardia occurred in 8% of cases with difficult intubation, while a significant decrease in oxygen saturation (SpO2<90% for 60 s or longer) occurred in 40%. Difficult tracheal intubation did not lead to a significant increase in 30- and 90-day morbidity or mortality. Recent evidence indicates that there are differences between neonates and older children. First, the incidence of difficult tracheal intubation is higher in neonates and infants than in older children.2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar,4Heinrich S. Birkholz T. Ihmsen H. Irouschek A. Ackermann A. Schmidt J. Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures.Paediatr Anaesth. 2012; 22: 729-736Crossref PubMed Scopus (141) Google Scholar Second, unexpected difficult intubation may occur more frequently in neonates and infants than in older children.2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar,5Fiadjoe J.E. Nishisaki A. Jagannathan N. et al.Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.Lancet Respir Med. 2016; 4: 37-48Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar So the generally accepted belief that ‘most children who have airways that are difficult to manage can be identified in advance’ may not be applicable to neonates and infants. Third, the incidence of hypoxaemia associated with tracheal intubation is higher in neonates and infants than in older children.5Fiadjoe J.E. Nishisaki A. Jagannathan N. et al.Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.Lancet Respir Med. 2016; 4: 37-48Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar Finally, when a conventional direct laryngoscope is used in neonates and infants with difficult airways, the success rate of tracheal intubation for the first attempt is extremely low.2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar,6Park R. Peyton J.M. Fiadjoe J.E. et al.The efficacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry.Br J Anaesth. 2017; 119: 984-992Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar So, what should we do when we encounter a neonate with an unexpected difficult airway? Disma and colleagues2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar report that experienced help was frequently sought, a practice that is in accordance with guidelines.1Black A.E. Flynn P.E. Smith H.L. Thomas M.L. Wilkinson K.A. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice.Paediatr Anaesth. 2015; 25: 346-362Crossref PubMed Scopus (94) Google Scholar They also report that, in neonates and infants with difficult airways, the success rate of intubation at the first attempt with a direct laryngoscope was merely 3% when a conventional laryngoscope was used. Such a low success rate (4%) with direct laryngoscopy has also been reported by Park and colleagues.6Park R. Peyton J.M. Fiadjoe J.E. et al.The efficacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry.Br J Anaesth. 2017; 119: 984-992Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Therefore, when difficult intubation is predicted, or intubation has failed twice, there is no reason to attempt to intubate the trachea using direct laryngoscopy. Videolaryngoscopy is potentially useful for tracheal intubation, and many studies have shown that videolaryngoscopy increases first pass success in tracheal intubation in children (including neonates and infants) with difficult airways.5Fiadjoe J.E. Nishisaki A. Jagannathan N. et al.Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.Lancet Respir Med. 2016; 4: 37-48Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 6Park R. Peyton J.M. Fiadjoe J.E. et al.The efficacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry.Br J Anaesth. 2017; 119: 984-992Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 7Burjek N.E. Nishisaki A. Fiadjoe J.E. et al.Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway: an analysis from the Multicenter Pediatric Difficult Intubation Registry.Anesthesiology. 2017; 127: 432-440Crossref PubMed Scopus (41) Google Scholar, 8Garcia-Marcinkiewicz A.G. Kovatsis P.G. Hunyady A.I. et al.First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial.Lancet. 2020; 396: 1905-1913Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 9Peyton J. Park R. Staffa S.J. et al.A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry.Br J Anaesth. 2021; 126: 331-339Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar These reports suggest that there should be a greater proscriptive emphasis of the use of videolaryngoscopy in paediatric airway management algorithms, particularly for the first attempt at tracheal intubation. The use of fibreoptic bronchoscopy is another reliable method to intubate the trachea. The bronchoscope can directly be inserted into the trachea, or can be guided through an already inserted supraglottic airway, to achieve tracheal intubation.7Burjek N.E. Nishisaki A. Fiadjoe J.E. et al.Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway: an analysis from the Multicenter Pediatric Difficult Intubation Registry.Anesthesiology. 2017; 127: 432-440Crossref PubMed Scopus (41) Google Scholar,10Asai T. Nagata A. Shingu K. Awake tracheal intubation through the laryngeal mask in neonates with upper airway obstruction.Paediatr Anaesth. 2008; 18: 77-80PubMed Google Scholar The success rate of insertion of a supraglottic airway is high in children with difficult airways,11Jagannathan N. Sequera-Ramos L. Sohn I. Wallis B. Shertzer A. Scjaldenbrand K. Elective use of supraglottic airway devices for primary airway management in children with difficult airways.Br J Anaesth. 2014; 112: 742-748Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar and successful insertion of which facilitates oxygenation. Overall, difficult airway management strategies in neonates and infants seem to be similar to the strategies in adults or older children, but there are some differences. Neonates and infants are at increased risk of oxygen desaturation, which often forces the clinician to abandon intubation attempts and then to multiple intubation attempts, thereby increasing the risk of additional complications. Many small children exhibit features of physiologic difficult airways given that multiple intubation attempts are reported despite reasonable glottic views.2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar,5Fiadjoe J.E. Nishisaki A. Jagannathan N. et al.Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis.Lancet Respir Med. 2016; 4: 37-48Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar,12Engelhardt T. Virag K. Veyckemans F. Habre W. Airway management in paediatric anaesthesia in Europe – insights from APRICOT (Anaesthesia PRactice in Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe.Br J Anaesth. 2018; 121: 66-75Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,13Habre W. Disma N. Virag K. et al.Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe.Lancet Respir Med. 2017; 5: 412-425Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar Apnoeic oxygenation by insufflating oxygen delays onset of hypoxaemia during attempts at tracheal intubation, and experts continue to advocate apnoeic oxygenation to minimise interruption of intubation attempts.14Fiadjoe J.E. Litman R.S. Oxygen supplementation during prolonged tracheal intubation should be the standard of care.Br J Anaesth. 2016; 117: 417-418Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 15Jagannathan N. Burjek N. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a step forward in apnoeic oxygenation, paradigm-shift in ventilation, or both?.Br J Anaesth. 2017; 118: 150-152Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 16King M.R. Jagannathan N. Best practice recommendations for difficult airway management in children – is it time for an update?.Br J Anaesth. 2018; 121: 4-7Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 17Riva T. Pedersen T.H. Seiler S. et al.Transnasal humidified rapid insufflation ventilatory exchange for oxygenation of children during apnoea: a prospective randomised controlled trial.Br J Anaesth. 2018; 120: 592-599Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 18Humphreys S. Lee-Archer P. Reyne G. Long D. Williams T. Schibler A. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial.Br J Anaesth. 2017; 118: 232-238Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar By incorporating this practice as standard of care whenever tracheal intubation is attempted in all neonates and infants, we can reduce multiple attempts at tracheal intubation, thereby reducing complications associated with repeated attempts. Videolaryngoscopy may not be as effective in small children as in older children or adults.19Lingappan K. Arnold J.L. Fernandes C.J. Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates.Cochrane Database Sys Rev. 2018; 6CD009975PubMed Google Scholar In adults with expected or unexpected difficult airways, the success rate of videolaryngoscope-aided tracheal intubation at the first attempt is high (90–99%).20Aziz M. Dilman D. Fu R. Barmbrink A. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway.Anesthesiology. 2012; 116: 629-636Crossref PubMed Scopus (214) Google Scholar,21Asai T. Liu E.H. Matsumoto S. et al.Use of the Pentax-AWS in 293 patients with difficult airways.Anesthesiology. 2009; 110: 898-904Crossref PubMed Scopus (185) Google Scholar In contrast, the first-attempt success rate of intubation in small children may be much lower than in large children, and one study has indicated a success rate of only 30% at the first attempt, with 70% eventual success.6Park R. Peyton J.M. Fiadjoe J.E. et al.The efficacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry.Br J Anaesth. 2017; 119: 984-992Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The reason for this lower success rate is not clear, but a possibility is that currently available videolaryngoscope blades in practice may not be consistently effective in exposing the glottis in small children. Additionally, tracheal tube delivery also may be difficult despite an adequate view of the glottis. These findings were confirmed by a study7Burjek N.E. Nishisaki A. Fiadjoe J.E. et al.Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway: an analysis from the Multicenter Pediatric Difficult Intubation Registry.Anesthesiology. 2017; 127: 432-440Crossref PubMed Scopus (41) Google Scholar that reported a significantly lower first pass success for tracheal intubation when a videolaryngoscope was used compared with fibreoptic intubation via a supraglottic airway in neonates and infants with difficult airways, whereas no such difference was observed in older children. Similar problems may be associated with fibreoptic bronchoscopy in neonates, as a fibreoptic bronchoscope with a small external diameter (<3 mm) may not be readily available. If both tracheal intubation and ventilation via a facemask have failed, a supraglottic airway is regarded as a rescue device. Insertion of a supraglottic airway is usually easy in children with difficult airways,10Asai T. Nagata A. Shingu K. Awake tracheal intubation through the laryngeal mask in neonates with upper airway obstruction.Paediatr Anaesth. 2008; 18: 77-80PubMed Google Scholar,11Jagannathan N. Sequera-Ramos L. Sohn I. Wallis B. Shertzer A. Scjaldenbrand K. Elective use of supraglottic airway devices for primary airway management in children with difficult airways.Br J Anaesth. 2014; 112: 742-748Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar but ventilation via a supraglottic airway may also fail. In adults, some factors are known to be risk factors for difficult ventilation via a supraglottic airway,22Saito T. Chew S.T.H. Liu W.L. Thinn K.K. Asai T. Ti L.K. A proposal for a new scoring system to predict difficult ventilation through a supraglottic airway.Br J Anaesth. 2016; 117: i83-i86Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar but risk factors may well be different in neonates. If ventilation via a supraglottic airway has failed, invasive front of neck airway access is indicated as the last resort. Emergency front of neck access may not be suitable in infants because it can be difficult to locate the cricothyroid membrane which is frequently <3 mm in size.23Navsa N. Tossel G. Boon J.M. Dimensions of the neonatal cricothyroid membrane - how feasible is a surgical cricothyroidotomy?.Paediatr Anaesth. 2005; 15: 402-406Crossref PubMed Scopus (71) Google Scholar What we can learn from the findings reported in this multicentre study,2Disma N. Virag K. Riva T. Kaufmann J. Engelhardt T. Walid Habre W. Difficult tracheal intubation in neonates and infants. NECTARINE: a prospective European multicentre observational study.Br J Anaesth. 2021 Mar 30; (S0007-0912(21)00116-1; Online ahead of print. PMID: 33812665r)https://doi.org/10.1016/j.bja.2021.02.021Abstract Full Text Full Text PDF Scopus (10) Google Scholar and what are our current and future goals? We should first be aware that, unlike in older children, unexpected difficult tracheal intubation occurs frequently in small children, and that the chance of successful intubation is quite low with direct laryngoscopy. Therefore, when tracheal intubation is unexpectedly difficult, we should maintain a clear airway without repeated attempts at intubation, call for help, and call for alternative intubation equipment (e.g. videolaryngoscope, fibreoptic bronchoscope, supraglottic airway) of suitable size and means to provide apnoeic oxygenation. We should then start apnoeic oxygenation and attempt to intubate the trachea either with a videolaryngoscope (with a stylet or a bougie readily available) or a fibreoptic bronchoscope. To carry out these steps efficiently and effectively, a policy based on current knowledge and resources available at each hospital should establish whether or not apnoeic oxygenation can be incorporated as standard of care, videolaryngoscopy should be regarded as the first choice for tracheal intubation in small children, and personnel with sufficient skills to manage the difficult airway in neonates should always be readily available. This would allow a structured checklist in the form of an airway ‘time out’ focusing on plans for appropriate device use, oxygenation, and experienced help beforehand to ensure that key steps and approaches are not overlooked. It is clear that airway management methods in small children are still not optimal. Therefore, it is time to carry out studies to assess the efficacy of each procedure, to develop suitable sizes of airway devices for neonates, and to establish more proscriptive recommendations and formal education for clinicians to minimise complications during difficult airway management, since neonates are quite different from children. NJ serves on the editorial boards of the Anesthesia and Analgesia, Pediatric Anesthesia, Journal of Clinical Anesthesia, and Journal of Anaesthesia. He has received products free of charge from Ambu and Teleflex corporations. He has received travel support for meetings involving future developments for upcoming airway devices from Teleflex, Vyaire Medical, and Mercury Medical. He has received stock options from Spiro. TA is an editor of the British Journal of Anaesthesia and the Journal of Anesthesia. Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational studyBritish Journal of AnaesthesiaVol. 126Issue 6PreviewNeonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. Full-Text PDF Open AccessMorbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)British Journal of AnaesthesiaVol. 126Issue 6PreviewNeonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Full-Text PDF Open Access