Management Of Difficult Airway In Children Research Articles

Error traps in pediatric difficult airway management.

Difficult airway management in children is associated with significant morbidity. This narrative review on error traps in airway management aims to highlight the common pitfalls and proposes solutions to optimize best practices for pediatric difficult airway management. We have categorized common errors of pediatric difficult airway management into three main error traps: preparation, performance, and proficiency, and present potential strategies to improve patient safety and successful tracheal intubation in infants and children with difficult airways.

Branchio-otic syndrome: An opportunity to reassess the paediatric anaesthetists’ approach to the difficult syndromic airway

Branchio-oto-renal spectrum disorders are rare genetic entities with variable penetrance and concurrently display a wide phenotypic variation. A common issue to syndromic children is a propensity for difficult bag-mask ventilation, intubation or both. Unfortunately, there is no uniformity of this challenge, assessment strategy or management plan. This case with features of branchio-otic syndrome provided the opportunity to examine several aspects of paediatric anaesthetic airway management. The child was booked for branchial cyst removal but appeared to have other features of abnormal branchial cleft development. An outline of the executed anaesthetic plan is presented and discussed. Three different techniques were sequentially tried in this patient before the airway was secured. Various case reports in the literature inconsistently describe easy to very difficult airway management in children with branchio-oto-renal spectrum disorders. Branchial arch dysgenesis is almost always associated with difficult direct laryngoscopy. There is undoubtedly no singular way to ideally manage a child with a difficult airway. Many tools for difficult airways are available. However, despite the improvement of difficult paediatric airway equipment, it would appear that for the anaesthetist the flexible bronchoscope remains an indispensable tool.

Focused review on management of the difficult paediatric airway.

Management of the difficult paediatric airway management may be associated with a high rate of complications. It is important that clinicians understand the patient profiles associated with difficult airway management, and the equipment and techniques available to effectively manage these children. The goal of this focused review is to highlight key airway management concepts when managing the paediatric difficult airway. This includes understanding the advantages and limitations of various airway equipment designed for children and reviewing the difficult airway algorithm with its unique considerations for the paediatric patient. Early recognition of known risk factors and thorough preparation may be helpful in reducing the risk of complications during difficult airway management in children.

Difficult airway management in children and young adults with arthrogryposis.

ObjectiveTo review current evidence and experience with anesthesia and airway management issues in children and young adults with arthrogryposis.Data sourcesReview of existing world literature and description of personal experience at a center for children's orthopedic surgery and rehabilitation over 2 decades.MethodsDescription of common problems and their solutions in this unusual and diverse group of patients.ResultsArthrogryposis multiplex congenital includes more than 400 conditions that lead to congenital joint contractures affecting more than one body area. Among the many causes of arthrogryposis, 50%–65% fall into two large categories – amyoplasia and distal arthrogryposis. There is general agreement that best function in children with arthrogryposis is achieved through early mobilization of joint contractures. Children with arthrogryposis average >5 operative procedures during childhood. Anesthesia for these procedures may be complicated by limited jaw mobility and mouth opening, restricted lung development, positioning difficulties, difficult venous access and concerns about increased risk for malignant hyperthermia. 75% of arthrogryposis patients do not have a difficult airway. For those with a history of airway problems or those meeting criteria for a difficult airway, careful advanced planning helps to assure safe and successful surgery. We describe several specialized techniques for endotracheal intubation of children with arthrogryposis.ConclusionsChildren and young adults with arthrogryposis are a diverse group. Many pose unique challenges for airway and surgical management. Review of individual anesthesia records and careful advanced planning by a coordinated, experienced airway team can lead to best outcomes from arthrogryposis surgery.

Unanticipated difficult airway management in children - the consensus statement of the Paediatric Anaesthesiology and Intensive Care Section and the Airway Management Section of the Polish Society of Anaesthesiology and Intensive Therapy and the Polish So.

Tracheal intubation may be defined as an artificial airway established in order to provide mechanical ventilation of the lungs during surgical procedures under general anaesthesia, treatment in an intensive care unit, as well as in emergency situations. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient's death. There may be unanticipated and anticipated difficult airway. Children form a specific group of patients as there are significant differences in both anatomy and physiology. There are some limitations in equipment used for the airway management in children. There are only few paediatric difficult airway guidelines available, some of which have significant limitations. The presented algorithm was created by a group of specialists who represent the Polish Society of Anaesthesiology and Intensive Therapy, as well as the Polish Neonatology Society. This algorithm is intended for the unanticipated difficult airway in children and can be used in all age groups. It covers both elective intubation, as well as rescue techniques. A guide forms an integral part of the algorithm. It describes in detail all stages of the algorithm considering some modifications in a specific age group, e.g. neonates. The main aim of Stage I is to optimise conditions for face mask ventilation, laryngoscopy and intubation. Stage IIA focuses on maximising the chances of successful intubation when face mask ventilation is possible. Stage IIB outlines actions aimed at improving face mask ventilation. Stage IIIA describes the use of a SAD (Supraglottic Airway Device) during effective face mask ventilation or in a CICV (Cannot Intubate, Cannot Ventilate) situation. Stage IIIB outlines intubation through a SAD. Stage IV describes rescue techniques and outlines possible options of either proceeding with surgery or postponing it, depending on clinical situation.

Managing the difficult airway in the syndromic child

A difficult airway as defined by the ASA Task Force on Management of the Difficult Airway is ‘the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both’. In a retrospective review of 11 219 paediatric procedures, the risk of difficult laryngoscopy was estimated as 1.35%. The risk was found to be higher in neonates and infants, children who are underweight, ASA physical status III and IV, or have Mallampati score III and IV. 1 However, the reliability of the Mallampati score in predicting difficult airway management in the paediatric population has been questioned and some clinicians prefer the Colorado Pediatric Airway Score (COPUR), since it uses a detailed scoring system and is therefore possibly more reliable. 2 Cooperation for airway assessment in children is not always easy and the availability of a score which accounts for a number of different aspects of the airway is more thorough. (See Table 1 for details.) Data pertaining to the real incidence of difficult airway management in children are sparse, but they are thought to be lower than in the adult population. Certain features predicting potential difficulties with airway management are often present in a number of syndromic children seen in paediatric anaesthesia practice. Predictors of difficult intubation include the presence of dysmorphic features, limited neck extension due to fusion of cervical vertebrae as found in Klippel‐ Feil syndrome, limited mouth opening, and restricted mobility of temporo-mandibular joints, a large tongue (macroglossia) such as found in Beckwith‐Wiedemann syndrome, limited submandibular space (retrognathia, micrognathia, mandibular hypoplasia or dysplasia) as found in Pierre Robin syndrome and Treacher Collins syndrome, and the presence of structural abnormalities in the laryngo-tracheal passage. Other predictors include soft tissue tumours, storage diseases such as mucopolysaccharidoses, and arteriovenous or lymphatic malformations involving the airway. In neonates and infants, the lateral profile may be more useful in eliciting the subtle signs of mandibular hypoplasia which are easily missed. (Refer to Table 2 for the anatomical site predominantly causing the airway problem in these syndromes.) This review focuses on some common syndromes predominantly seen in paediatric anaesthesia practice that are associated with potentially difficult airway management and highlights the related relevant features. A broader discussion of difficult intubation in the paediatric population has been published elsewhere and is beyond the scope of this review. 34

Comparison of the air-Q intubating laryngeal airway and the cobra perilaryngeal airway as conduits for fiber optic-guided intubation in pediatric patients.

Background:One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients.Materials and Methods:A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications.Results:Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH2O vs. 16.3 ± 4.5 cmH2O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat.Conclusion:Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.

A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study

Difficult airway management in children is challenging. One alternative device to the gold standard of direct laryngoscopy is the STORZ Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany), a rigid fiberoptic stylette-like scope with a curved tip. Although results in adults have been encouraging, reports regarding its use in children have been conflicting. We compared the effectiveness of a standard laryngoscope to the Bonfils fiberscope in a simulated difficult infant airway. Ten pediatric anesthesiologists were recruited for this study and asked to perform three sets of tasks. For the first task, each participant intubated an unaltered manikin (SimBaby (TM), Laerdal, Puchheim, Germany) five times using a styletted 3.5 endotracheal tube (ETT) and a Miller 1 blade (group DL-Normal). For the second task, a difficult airway configuration simulating a Cormack-Lehane grade 3B view was created by fixing a Miller-1 blade into position in the manikin using a laboratory stand. Each participant then intubated the manikin five times with a styletted 3.5 ETT using conventional technique but without touching the laryngoscope (group DL-Difficult). In the third task, the manikin was kept in the same difficult airway configuration, and each participant intubated the manikin five times using a 3.5-mm ETT mounted on the Bonfils fiberscope as an adjunct to direct laryngoscopy with the Miller-1 blade (group BF-Difficult). Primary outcomes were time to intubate and success rate. A total of 150 intubations were performed. Correct ETT placement was achieved in 100% of attempts in group DL-Normal, 90% of attempts in group DL-Difficult and 98% of attempts in BF-Difficult. Time to intubate averaged 14 s (interquartile range 12-16) in group DL-Normal; 12 s (10-15) in group DL-Difficult; and 11 s (10-18) in group BF-Difficult. The percentage of glottic opening seen (POGO score) was 70% (70-80) in group DL-Normal; 0% (0-0) in group DL-Difficult; and 100% (100-100) in group BF-Difficult. The Bonfils fiberscope-assisted laryngoscopy was easier to use and provided a better view of the larynx than simple direct laryngoscopy in the simulated difficult pediatric airway, but intubation success rate and time to intubate were not improved. Further studies of the Bonfils fibrescope as a pediatric airway adjunct are needed.

Evaluation of the pediatric bonfils fiberscope for elective endotracheal intubation

Difficult airway management in children is a particular challenge for anesthesiologists and pediatricians. This study was designed to evaluate the performance of the recently developed pediatric versions of the Bonfils fiberscope for elective endotracheal intubation during routine surgical procedures. After approval by the institutional review board and written informed consent, 55 children (age 6 +/- 4 years) scheduled for elective minor surgical procedures were enrolled. Nineteen children received atropine before the intubation attempt, while in the remaining 36 children, no antisialogogue was used. For endotracheal tubes up to 3.5 mm internal diameter, a fiberscope with outer diameter (OD) 2 mm, and for larger endotracheal tubes, a fiberscope OD 3.5 mm was used. Time to intubation and failure rate were obtained. In the 36 children without and the 19 children with atropine pretreatment, the success rate for tracheal intubation on the first attempt was 69%/78% (25/15 patients). 4/3 patients and 2/0 patients were intubated after two and three attempts, respectively, and in 5/1 patients (14%/5%) intubation failed even after three attempts. Time to intubation was median 58/60 s, 25th-75th percentile 35-100/32-110 s, and range 14-377/18-360 s. In both groups, failed intubations were because of the secretions contaminating the optic aperture. High failure rate and increased intubation times suggest that the pediatric Bonfils fiberscope has significant drawbacks when used for intubation of normal pediatric airways.

Laryngeal mask airway and difficult airway management in children: A report of 2 cases

Laryngeal mask airway and difficult airway management in children: A report of 2 cases