Airway Management In Pediatric Patients Research Articles

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Effectiveness of Training: Airway Management of Tracheostomized Pediatric Patients by Pediatric Residents and Anesthesiology Residents.

To evaluate the effect of training on increasing baseline knowledge of pediatrics and anesthesia residents about airway management of pediatric patients with tracheostomy. It is a prospective, descriptive, before and after survey study. A questionnaire was conducted to measure the baseline knowledge of pediatrics and anesthesia residents about airway management in patients with pediatric tracheotomy. The same questionnaire was repeated after the education. Of the 63 participants, 42 were pediatric residents and 21 were anesthesiology residents. While the number of participants who answered the cuff part, inner cannula part, obturator part and balloon part of the tracheostomy tube correctly before the training was 27, 4, 10, and 12, respectively, these numbers increased to 53, 52, 57, and 55 after the training. There was a statistically significant improvement after the training in the correct response of the cuff, inner cannula, obturator, and balloon sections. A statistically significant improvement was observed in the answers received after the training for all 7 questions regarding the clinical scenario of accidental decannulation and tracheostomy bleeding compared to the pre-training. There was a statistical improvement in part where the participants rated themselves. In conclusion, training increases the ability of healthcare professionals to cope with life-threatening complications related to pediatric tracheotomy. A standardized education program on pediatric tracheostomy should be included in the routine programs of associated departments such as emergency medicine, anesthesia, and pediatrics residencies.

Airway Management in Pediatric Patients: Cuff-Solved Problem?

Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.

Airway Management in Pediatric Patients With Burn Contractures of the Face and Neck.

Burn injury is a common cause of trauma. Non-fatal burn injuries are a leading cause of morbidity, and significant numbers of the victims are children. Scar contracture after burn injury can cause severe functional limitation, pain, and aesthetic and psychological problems and patients may present for contracture release and reconstructive surgery. The aim of this systematic review was to identify research relevant to airway management of children with burn contracture of the face and neck with special emphasis on awake airway management and airway anesthesia, and synthesize results that can aid practice. Literature search was performed on Medline, PubMed, Cochrane Library, and Google Scholar with selected keywords. The search was restricted to human subjects of ≤18 year age, there was no language or time restriction, and the final search was concluded in July 2021. The review included 41 articles involving airway management of 56 patients in 61 anesthesia episodes. Patients aged between 8 months to 18 years. Mask ventilation and direct laryngoscopy, video laryngoscopy, optical stylet, supraglottic airway, flexible scope intubation and tracheostomy, and extracorporeal membrane oxygenation were the devices and methods used for securing the airway and oxygenation while the patients were awake or after anesthesia induction. Detailed planning and patient preparation are the fundamentals of airway management of pediatric patients with burn contracture of the face and neck; awake airway management with airway anesthesia can be safely used in selected patients. This review provides information for good clinical practice and might serve to improve the care of such children.

Improvement of Pediatric Advanced Airway Management in General Emergency Departments After a Collaborative Intervention Program.

In general emergency departments, advanced airway management of pediatric patients who are critically ill has been associated with increased adverse events given the varying exposure to pediatric patients and limited resources. Previous studies have shown significant improvement of simulated pediatric airway management in general emergency departments. The aim of this retrospective study was to determine the effect of an in situ simulation-based collaborative intervention program on the actual care of pediatric airway management in general emergency departments. This was a retrospective study of pediatric subjects who were critically ill and required intubation at a diverse set of general emergency departments before referral to the academic medical center. The primary outcome was the quality of clinical care measured by adherence to best practices via a critical action checklist. Secondary outcomes included tracheal intubation associated adverse events and clinical outcomes. A total of 135 pediatric subjects (48 pre- and 87 post-intervention) who were transferred to the academic medical center from 9 general emergency departments between May 2014 and August 2019 were included in the analysis. The use of a cuffed endotracheal tube improved, from 44% to 72% (P = .001), whereas there was no significant change in the appropriate endotracheal tube size. Overall, severe tracheal intubation associated adverse events decreased, from 18.8% to 9.2% (P = .03), and post-intubation cardiac arrest events decreased, from 6.3% to 0% (P = .02). A simulation-based collaborative intervention program led to improvement in pediatric airway management and subject outcomes in general emergency departments. This model demonstrated the transfer of improvement from a simulated setting to a clinical setting and may be targeted in other clinical settings.

Comparison of I-gel and Proseal LMA for airway management in pediatric patients under controlled ventilation - A prospective, randomized, single blind clinical study

Introduction: The Proseal Laryngeal Mask Airway (PLMA) and I-gel are two novel supraglottic devices available for airway management and can be used safely in paediatric patients. The primary aim of our study was to compare the efficacy of PLMA and I-gel in providing adequate airway seal in paediatric patients under controlled ventilation. Materials and Methods: A prospective, randomized, single blind clinical study was carried out during October 2014 to September 2015. A total of 64 ASA PS grade I and II paediatric patients (Aged 3-9 years) undergoing elective general surgery were included. Patients with upper respiratory tract infection and difficult intubation were excluded. The patients were randomly assigned into two groups PLMA Group and I-gel Group using randomizer software. We assessed airway insertion time, ease of insertion and number of attempts for airway control and gastric tube placement, oropharyngeal seal pressure, hemodynamic parameters and complications. Results: The oropharyngeal seal pressure was significantly higher (p=0.0025) in group PLMA (29.1±3.7cm of H2O) than in group I-gel (26.3±3.5 cm of H2O). Hemodynamic parameters, success rate and postoperative complications were comparable among both the groups. Conclusion: Both, PLMA and I-gel can be used safely and effectively for airway management in paediatric patients under controlled ventilation. Keywords: I-gel, PLMA, Paediatric patient, Controlled ventilation.

Comparison of the Effect of Laryngeal Mask Airway Versus Endotracheal Tube on Airway Management in Pediatric Patients with Tonsillar Hypertrophy

PurposeThe laryngeal mask airway (LMA) has become an important choice in both routine and difficult airway management. We aimed to evaluate the safety and effectiveness of LMA use in pediatric patients with tonsillar hypertrophy. DesignThis study was a randomized controlled trial. MethodsThe study included 100 pediatric patients who had first or second degree tonsillar hypertrophy. Pediatric patients undergoing elective laparoscopic inguinal hernia repair were randomly divided into two groups (n = 50): LMA group and the endotracheal tube (ETT) group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (PETco2). Data for primary outcomes were collected before and 5-, 15-, and 25-minute after opening pneumoperitoneum, and on closing the pneumoperitoneum. Complications such as laryngospasm, bronchospasm, desaturation, severe coughing, blood on the device after removal, and sore throat were recorded. FindingsA total of 100 pediatric patients were assessed and 97 eligible patients were randomly assigned to receive an LMA (n = 49) or an ETT (n = 48). There was no statistically significant difference in ventilation leak volume and PETco2 between the LMA and ETT groups (P > .05). Compared with T1-4, peak airway pressure was significantly lower in T0 (LMA group 12.6 ± 0.9, 95% confidence interval 12.2 to 13.0; ETT group 12.8 ± 1.2, 95% confidence interval 12.2 to 13.3; P < .05). The incidences of laryngospasm 11 (22.9%), desaturation 18 (37.5%), and severe coughing 13 (27%) were higher in the ETT group (11 [22.9%] vs 3 [6.1%], 18 [37.5%] vs 6 [12.2%], 13 [27%] vs 3 [6.1%]; P < .05). ConclusionsThe application of LMA has a lower incidence of complications. LMA as an airway device is effective and perhaps superior in appropriate patients.

Meta-Analysis of Failure of Prehospital Endotracheal Intubation in Pediatric Patients.

Prehospital care is essential for airway preservation in pediatric patients who require early endotracheal intubation to improve oxygenation and prevent aspiration. However, high frequencies of failure of endotracheal intubation have been reported for this age group. We aimed to analyze the frequency of failure of endotracheal intubation in pediatric patients within a prehospital context and compare it with adult patients. Thus, a systematic revision of literature with a meta-analysis was performed using a study search and selection strategy ensuring extensiveness, sensitivity, and reproducibility. Meta-analyses were performed for odds ratio, DerSimonian and Laird's Q test was used to assess heterogeneity, and Egger and Begg's test was used to assess publication bias. Overall, 17 papers and 8772 patients were included, and the main cause of prehospital care was assessed to be trauma. Failed endotracheal intubation frequency was 0.4%–52.6% in pediatric patients. The most frequent complication was with esophageal intubation. Forest plot suggests that risk of failure during intubation of pediatric patients is 3.54 fold higher than that observed for adults. It was concluded that airway management in pediatric patients within a prehospital context is a challenge for prehospital care providers because it entails clear physiological and anatomical differences and a low frequency of exposure to this kind of events as opposed to adults. These differences support a widely higher risk of failure of intubation, suggesting the necessity of consistently trained prehospital care providers to ensure proficiency in technique as well as availability of the required equipment.

Emerging trends, techniques, and equipment for airway management in pediatric patients.

Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.

Management of Pediatric Airway in Anesthesia

Airway management is a major competence of clinical anesthesia. Knowledge of available materials and skills in the use of specific methods and techniques are essential and should be trained routinely. In 2011 the scientific working group in pediatric anesthesia (WAKKA) of the German Society for anesthesia and intensive care medicine (DGAI) published a treatment recommendation for the management of the unexpected difficult pediatric airway. Furthermore, a recommendation for the management of the expected difficult pediatric airway is currently being compiled and the draft is available on the WAKKA homepage. For the airway management in pediatric patients, special materials, techniques, individual and institutional expertise must be present. This article presents a selection of materials, methods and techniques of the treatment recommendations for the management of a difficult airway.

Airway management of pediatric patients with burn induced oral nasal and mentosternal scar contractures: A case series

Airway management of pediatric patients with burn induced oral nasal and mentosternal scar contractures: A case series

Airway management of pediatric patients with facial and neck burn injury during grafting: A case series

Airway management of pediatric patients with facial and neck burn injury during grafting: A case series

Optimum cuff pressure of flexible laryngeal mask airway for airway management in pediatric patients

Objective To determine the optimum cuff pressure of the flexible laryngeal mask airway(LMA)for airway management in pediatric patients. Methods One hundred and twenty pediatric patients undergoing strabismus surgery with general anesthesia, of American Society of Anesthesiologists physical statusⅠ or Ⅱ, aged 3-10 yr, were randomly divided into 3 groups(n=40 each)according to the cuff pressure of the flexible LMA: 20 cmH2O pressure group(group A), 40 cmH2O pressure group(group B)and 60 cmH2O pressure group(group C). The cuff was inflated to the predetermined pressure using the inflatable cuff manometer in each group.Oropharyngeal leak pressure was measured after LMA placement.Peak airway pressure and the difference between inhaled and exhaled tidal volume were recorded at 5 min of positive pressure ventilation.The LMA insertion condition, LMA removal time, and development of sore throat, hoarseness, dysphagia and abdominal distention within 24 h after operation were recorded. Results There were no significant differences in the success rate of LMA placement at first attempt, peak airway pressure, or incidence of sore throat among the three groups(P>0.05), and no hoarseness or dysphagia was found in the three groups.Compared with group A, oropharyngeal leak pressure was significantly increased, and the difference between inhaled and exhaled tidal volume and incidence of abdominal distention were decreased in B and C groups(P 0.05). Conclusion The optimum cuff pressure of the flexible LMA is 40 cmH2O when used for airway management in the pediatric patients. Key words: Laryngeal masks; Respiration, artificial; Pressure

SIMPLE, TIMELY, SAFELY? LARYNGEAL MASK AND PEDIATRIC AIRWAY

Laryngeal mask airway (LMA) was a useful, powerful airway management device for routine pediatric airway management, pediatric difficult airway, and in pediatric emergency situations. Over years, various designs, induction and insertion techniques have been described. LMA provides ease of placement and removal as compared with endotracheal intubation, less traumatism for the respiratory tract, better tolerability by patients, improved hemodynamic stability during emergency, less coughing, less sore throat, avoidance of laryngoscopy, and hands free airway. On the other hand, LMA is not suitable to overcome functional airway problems and mechanical airway obstruction in children. Simple airway management in pediatric patients is normally easy in experienced hands, for anesthesiologists working in specialized hospitals with appropriate personnel and equipment that guarantee optimal safety in these patients. On the other hand, pediatric airway management is a great challenge for anesthesiologists working in departments with a small number of pediatric surgical procedures. Careful preoperative evaluation, preparation and training in the recognition of challenges in pediatric airway are essential for the management of the airway in children. LMA plays a special role in the management of difficult pediatric airway; as a supraglottic airway device, it is incorporated into difficult pediatric airway algorithms.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

OBJECTIVE:Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation.METHODS:In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis.RESULTS:A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation.CONCLUSION:All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients.

The use of a double‐lumen central venous catheter for airway management in pediatric patients undergoing laryngeal papillomatosis surgery

To evaluate the efficacy and safety of a spontaneous ventilation anesthesia technique with insufflation of oxygen and volatile agent through a double-lumen central venous catheter (DLCVC) in pediatric patients undergoing suspension laryngoscopic surgery for laryngeal papillomatosis. Thirty-six pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery were anesthetized with oxygen and volatile anesthetic insufflation while spontaneously breathing. Anesthesia was induced by inhalation of 8% sevoflurane in oxygen by mask. Atropine, dexamethasone, lidocaine, and midazolam were administered intravenously. The tip of a 7Fr DLCVC was inserted below the glottis after placement of the laryngoscope and establishing suspension. Anesthesia was maintained with insufflation of 4-6% sevoflurane and oxygen with a total fresh gas flow of 6 l·min(-1) through the 14G (larger lumen) of the DLCVC. Endtidal carbon dioxide tension (PetCO2) was monitored using the other lumen of the DLCVC, which was connected to the CO2 sampling line. Duration of the procedure as well as total anesthesia time was recorded. Electrocardiography (ECG), heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and PetCO2 were also monitored. Arterial blood was sampled for blood gas analysis including pH, PaO2 , PaCO2 , and actual base excess (ABE). Complications, including intraoperative patient movement, hypoxemia (SpO2 < 95% during oxygen insufflation), nausea, vomiting, bronchospasm, and arrhythmias, were recorded. There was a significant increase in PetCO2 and PaCO2 (P values <0.05) as well as a decrease in ABE, pH, and PaO2 (P values <0.05) in samples collected before and after surgery. MAP, HR, and SpO2 after surgery were not significantly different from after induction values (P values >0.05). During surgery, SpO2 < 95% in three cases and body movements in three cases were observed. No patient had any other of the complications previously described. Furthermore, no postsurgical endotracheal intubation was needed in any patient. After establishing an adequate depth of anesthesia, a spontaneous ventilation anesthesia technique with insufflation of oxygen and volatile agent through a DLCVC is feasible in pediatric patients undergoing suspension laryngoscopic surgery for laryngeal papillomatosis.

Airway Management following Pediatric Cardiothoracic Surgery

(1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population. Case series with chart review. Setting Tertiary care children's hospital. Patients Children undergoing CTS over a 4-year period. Patients who underwent CTS at a single, tertiary care, children's hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those <18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery. Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy. In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.

Comparison of the efficacies of I-gel^{TM} and LMA-ProSeal^{TM} for airway management in pediatric patients

The present study was performed to compare the performance of I-gel^{TM} with LMA-ProSeal^{TM} in children undergoing anesthesia. Materials and methods: A total of 185 patients who were scheduled for elective surgery in Dicle University's hospital were randomly divided into 2 groups: the I-gel^{TM} group (Group-I, n = 95) and the p-LMA^{TM} group (Group-P, n = 90). Airway leakage pressure, insertion time, fiberoptic laryngeal image scores, ease of insertion, and possible complications were compared between these groups. Results: The airway leakage pressure of Group-I was significantly higher than that of Group-P (means ± SD: 28 ± 5 vs. 20 ± 4 cmH_2O, P < 0.01). The duration of supraglottic airway device insertion was shorter in Group-I than Group-P (19 ± 4 vs. 28 ± 5 s, P < 0.01). The overall success rate was 95% for Group-I and 94% for Group-P (P = 0.10). The I-gel provided a better view of the glottis than the p-LMA (93% of cases in Group-I and 68% of cases in Group-P, P = 0.03). There were no significant differences with regard to ease of insertion (P = 0.97). Conclusion: This study suggested that I-gel is an effective and safe alternative supraglottic airway device for use in children.

Airway Management following Pediatric Cardiothoracic Surgery

Objective: Little is currently known regarding outcomes in airway management of pediatric patients following cardiothoracic surgery (CTS). This study aims to 1) review airway management in a large cohort of pediatric patients undergoing CTS and 2) determine the incidence of airway related complications of CTS in this population. Method: All patients who underwent CTS at a single, tertiary care, dedicated children’s hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those &lt;18 years old who had open CTS were included. Statistical analysis examined the relationships of intubation length, tracheotomy, and complications compared to patient characteristics, comorbidities, and type of surgery. Results: Nine hundred five admissions in 762 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days (d), and the median was 3 d. Significantly longer postoperative intubation requirements were found in patients &lt;2 years (mean 9.7 d, median 4 d) vs &gt;2 years (mean 2.4 d, median 2 d, P &lt; .001) and those with comorbidities (mean 11.0 d, median 4 d) or history of prematurity (mean 8.8 d, median 4 d) vs those without comorbidity (mean 5.5 d, median 3 d, P &lt; .001). Additionally, preoperative intubation and surgical incision type significantly affected intubation duration. Vocal cord paralysis occurred in 3 patients, and phrenic nerve palsy occurred in 5. Twenty-four patients required tracheotomy. Five patients developed airway stenosis. Conclusion: After reviewing a large cohort of patients, this study finds CTS in the pediatric population is associated with few long term or permanent airway related complications. Patients with a history of prematurity, medical comorbidity, and/or younger age at the time of surgery require longer periods of postoperative intubation.

Airway management for occipital encephalocele in neonatal patients: A review of 17 cases

Introduction:Encephalocele, midline defect of cranial bone fusion, occurs most frequently in the occipital region. Airway management in pediatric patients with craniofacial disorders poses many challenges to the anesthesiologist. The purpose of this study is to describe the airway problems encountered for such cases, and describe how these problems were managed.Materials and Methods:We reviewed the charts of occipital encephalocele newborn that were treated by surgical correction in Harran University Hospital during 2006–2008. The collected data were categorized into preoperative, intraoperative, and postoperative data.Results:The mean age of the patients was 5.17 days. Of these 17 patients, eight patients (47.1%) had hydrocephaly, one patient (5.8%) with Dandy Walker syndrome. Micrognathia, macroglossia, restriction in neck movements were recorded as the reasons in six cases each. No major anesthetic complication was found.Conclusions:We reported perioperative management in 17 occipital encephalocele infant. Comprehensive care during peroperative period is essential for successful outcome.