Difficult Pediatric Airway Research Articles

Paediatric airway and challenges during covid era

Pediatric airway brings some unique challenges to anesthesiologist. Anaesthesiologists are at particularly high risk of being exposed to Covid cases because airway management, particularly tracheal intubation, positive pressure ventilation through a mask, and management of tracheostomy tubes, causes widespread aerosolization of the virus. But these cases cannot be deferred. The aim is to present a case series of difficult pediatric airway scenarios managed successfully with different techniques and airway gadgets during COVID times taking all safety precautions. The following cases were managed successfully with appropriate airway techniques from the period of April 2020 to September 2021 in our institute.First case series of Tracheobronchial foreign bodies removal using controlled ventilation. Secondly Juvenile onset recurrent laryngeal papillomatosis for excision under coblation, one case managed by tubeless anesthesia and other by intubation using videolarygoscopy. Third case scenarios of Laryngeal web for excision with MLS scissor managed by LMA followed by tracheostomy. These airway related complications during COVID era, not only had logistic problems but also to optimize and work in a coordinated way with ENT surgeon in the common airway is a challenging task. These three case scenarios of pediatric airway during COVID times, were successfully managed with appropriate airway gadget suitable for each case without any complications.

Clinical evaluation of Ambu® AuraGain™ as a conduit for intubation in paediatric patients: a descriptive study

Introduction: Many paediatric difficult airway guidelines have recommended supraglottic airway devices (SGAs) as an indispensable tool in the algorithm for managing failed intubation scenarios. It is used for maintaining ventilation in a difficult or failed intubation. The newer generation SGAs can be used as intubating conduits in patients with a difficult airway. The aim of this study was to report the efficacy and safety of Ambu® AuraGain™(Ambu A/S, Ballerup, Denmark) as a conduit for intubation in paediatric patients.Methods: Local ethics approval and informed consent were obtained before patient enrolment. Sixteen patients aged 3–12 years old were recruited. Following the induction of anaesthesia and insertion of the Ambu AuraGain, fibreoptic guided intubation was performed via the SGA. The primary outcome was the time taken for successful tracheal intubation. Secondary outcomes included the number of attempts and the time required for insertion and removal of Ambu AuraGain, oropharyngeal leak pressures, fibre optic grading of glottic views, and complications from the intubation.Results: The overall success rate concerning intubation was 87.5% (14 patients), with a mean intubation time of 57.0 ± 39.4 seconds. Successful first attempt intubations were achieved in 13 patients (81.3%). The results showed easy removal of the Ambu AuraGain device with a mean SGA removal time of 27.2 ± 19.8 seconds. No significant complications occurred throughout the study.Conclusion: The Ambu AuraGain device can be considered safe and effective as a conduit for intubation in paediatric patients.

Asleep Fibreoptic Bronchoscope-Guided Nasal Intubation in a Child with Bilateral Temporomandibular Joint Ankylosis

Pierre Robin sequence (PRS) with bilateral temporomandibular joint (TMJ) ankylosis is a rare and challenging case for anaesthesiologists. A 6-year-old girl with PRS along with bilateral progressive TMJ ankylosis was scheduled for gap arthroplasty. Her mouth opening was <1 finger. Securing the airway in a syndromic child with mandibular hypoplasia was challenging. We performed an asleep fibreoptic bronchoscope (FOB)-guided nasotracheal intubation while retaining spontaneous breathing. Managing a difficult paediatric airway needs expertise. We believe that with the use of FOB, difficult airways can be successfully and safely managed.

Smith’s Anesthesia for Infants and Children, 10th Edition

Smith’s Anesthesia for Infants and Children, 10th Edition

Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team‐focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

Channeled videolaryngoscope assisted fiberoptic intubation in a Peter plus syndrome with difficult Pediatric Airway.

Channeled videolaryngoscope assisted fiberoptic intubation in a Peter plus syndrome with difficult Pediatric Airway.

Anesthetic challenges in an infant with multiple structural airway anomalies

Airway anomalies such as laryngomalacia, laryngeal webs, micrognathia, and retrognathia cause respiratory distress in infants and pose a significant challenge in anesthetic management. We report the case of a 2-month-old infant with laryngomalacia on continuous positive airway pressure support since birth, posted for laryngeal surgery, who was found to have micro-retrognathia during pre anaesthesia checkup. Securing the airway and preventing hypoxia were the main challenges in this child. Adequate measures were taken for continuous oxygenation during induction of anesthesia. The child underwent supraglottoplasty with an uneventful intraoperative course. However, the airway obstruction persisted in the postoperative period requiring a surgical tracheostomy. The child subsequently underwent mandibular distraction surgery after 1 month and was discharged with a tracheostomy tube. Although various anesthetic options have been described to manage the difficult pediatric airway, the anesthetic technique should be customized to ensure airway patency and oxygenation in the perioperative period as illustrated in this case report.

Use of video laryngoscope in a difficult paediatric cleft palate airway: Rescue or primary airway device?

Use of video laryngoscope in a difficult paediatric cleft palate airway: Rescue or primary airway device?

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.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Low-cost versus high-fidelity pediatric simulators for difficult airway management training: a randomized study in continuing medical education

BackgroundHigh-fidelity (HF) pediatric patient simulators are expensive. This randomized study aimed to compare the quality and educational impact of a full-scale simulation workshop with an HF infant simulator (SimBaby™, Laerdal) or with a low-cost (LC) simulator composed of an inert infant manikin with SimBaby™ software that displays respiratory/hemodynamic parameters on a monitor for medical education in pediatric difficult airway management. MethodsAfter written informed consent, anesthetists and emergency or ICU physicians participated in teams (4 to 6 participants) in a training session that included direct participation and observation of two difficult intubation scenarios. They were randomized into two groups (HF group, n = 65 and LC group, n = 63). They filled out a simulation quality score (SQS, 0 to 50), self-evaluated their anesthetists’ non-technical skills (ANTS) score (15 to 60), and an educational quality score (EQS, 0 to 60) immediately (T0, main criteria), as well as 3 (T3) and 6 (T6) months after the training session. ResultsWe enrolled 128 physicians. Direct participation SQS (39 ± 5 HF group versus 38 ± 5 LC group), observation SQS (41 ± 4 H F group versus 39 ± 5 LC group), ANTS scores (38 ± 4 HF group versus 39 ± 6 LC group), T0 SQS (44 ± 5 HF group versus 43 ± 6 LC group), T3 and T6 SQS were not different between groups. ConclusionOur low-cost simulator should be suggested as a less expensive alternative to an HF simulator for continuing medical education in pediatric difficult airway management.

A Primer for Pediatric Emergency Front-of-the-Neck Access.

"Cannot intubate, cannot oxygenate" situations in healthy children are uncommon but are often associated with poor outcomes. Clinical assessment, anticipatory planning, and the use of algorithms can lessen the likelihood of untoward outcomes, but the common final pathway of many algorithms for a difficult pediatric airway involves obtaining emergency tracheal access. The airway practitioner must have the know-how and training needed to invasively secure the airway when confronted with this rare but potentially devastating emergency. We provide practitioners with an overview of pediatric emergency front-of-the-neck access strategies and a structure for their management.

Dexmedetomidine vs Fentanyl for Awake Fiberoptic Intubation in Paediatric Patients with Temporomandibular Joint Ankylosis: A Retrospective Analysis

Introduction: For successful management of difficult paediatric airway intubation, proper preparation of airway along with a calm and sedated child with titrated doses of sedative agents is paramount. Aim: To compare two different classes of sedative agents (Dexmedetomidine vs Fentanyl) regarding intubating conditions and comfort score of paediatric population at the time of awake fiberoptic intubation. Materials and Methods: This retrospective study was carried out among 40 paediatric patients, aged between 5-14 years those who underwent surgery for Temporo-Mandibular Joint (TMJ) ankylosis. Clinical data relevant for this study was collected from the pre-format sheets of anaesthesia technique, attached with case files of the patients. Inj. dexmetedomidine bolus of 1 mcg/kg for 10 minutes followed by infusion at the rate 0.6 mcg/kg/hr in group A and Inj. fentanyl bolus dose of 2 mcg/kg followed by infusion 1 mcg/kg/hr in group B were compared in terms of intubating conditions and patient co-operation. For data analysis Statistical Package for the Social Sciences (SPSS) version 20 (IBM Inc.) was used. Patient characteristics in the two groups were compared using mean±SD and chi-square test. Results: All the patients had successful intubation in first attempt in both the groups. In terms of airway preparation, out of total, 14 (35%) patients in group A had no secretions as compare to 4 (10%) patients of group B (p-value was 0.002). In terms of cough score, 13 (32.5%) patients in group A had no cough as compared to 3 (7.5%) patients in group B. Patients in group A were more comfortable at the time of insertion of Flexible Fiberoptic Bronchoscopy (FOB) with no or less resistance to FOB insertion (p-value was 0.043). Vocal cord conditions were favourable in both the groups and there was no difference. Conclusion: Fiberoptic nasal intubation was found to be easier and safe in terms of patient comfort and preservation of patent airway with the use of dexmedetomidine, in paediatric TMJ ankylosis.

Ureteral guidewire, an adjunct for the paediatric difficult airway management

Ureteral guidewire, an adjunct for the paediatric difficult airway management

Management of the Difficult Pediatric Airway

This review discusses the most current relevant literature regarding management of the difficult pediatric airway. Periodic review of the latest research ensures that anesthesia providers are educated on the most current practices. The review will provide practical evidence to support the use of various devices and techniques, including video laryngoscopy, flexible fiberoptic bronchoscopy, apneic oxygenation, use of neuromuscular blockade, ultrasound, and more. A simple algorithm for managing the difficult pediatric airway is also provided. Understanding the risk factors for the difficult pediatric airway, along with thorough preparation, will aid in reducing complications, which can be devastating. Providers must maintain proficiency in the skills, both traditional and novel, required to effectively and safely manage the expected and unexpected difficult pediatric airway.

Comparison of the MultiViewScope Stylet Scope and the direct laryngoscope with the Miller blade for the intubation in normal and difficult pediatric airways: A randomized, crossover, manikin study.

Managing difficult pediatric airway is challenging. The MultiViewScope (MVS) Stylet Scope is reported to be useful in difficult pediatric airway. In this randomized crossover study, we compared the effectiveness of the MVS Stylet Scope to a standard direct laryngoscope with Miller #1 blade in simulated normal and difficult airways. Fifteen expert anesthesiologists and Fifteen anesthesiology residents participated in the study. Participants were asked to perform intubation with the Airsim Baby manikin first, and then with the Airsim Pierre Robin manikin. Participants in each group used the intubation devices in a randomized order. The primary outcome was the time of successful intubation. The secondary outcomes were the force exerted on the incisors during intubation, Cormack-Lehane scale, the difficulty of intubation. There were no differences between MVS Stylet Scope and Direct laryngoscope in the time of successful intubation by the expert anesthesiologists or the anesthesiology residents in a normal or difficult pediatric airway. MVS Stylet Scope significantly improved the force exerted on the incisors during intubation in the expert anesthesiologists or the anesthesiology residents in a normal or difficult pediatric airway. MVS Stylet Scope significantly improved Cormack-Lehane scale, and the difficulty of intubation with difficult pediatric airway situation in both expert anesthesiologists and anesthesiology residents. Although less forces on the incisors and improved view of glottis were observed with the MVS Stylet Scope, MVS Stylet Scope did not shorten the time of intubation. The results of this study mean that the MVS Stylet Scope may be a less invasive airway devise than the direct laryngoscope with the Miller blade in the pediatric airway management. For the next step, we need to evaluate the MVS Stylet Scope in the real patients as an observational study.

Management of a Difficult Airway Scenario in a Case of Hurler’s Syndrome with a D-Blade Video Laryngoscope

AbstractHurler’s syndrome is a rare genetic disease characterized by progressive multiorgan accumulation of glycosaminoglycans. It is associated with progressive craniofacial, skeletal, and cardiac involvement, which increases the risk of anesthesia. Patients with Hurler’s syndrome could present as the worst airway management problem an anesthesiologist could deal with due to abnormal upper airway anatomy and limited neck manipulation, owing to the atlantoaxial instability. We report a case of difficult airway scenario of a child with Hurler’s syndrome, leading to an apparent cannot ventilate cannot intubate scenario, which was managed successfully with the help of a C-MAC video laryngoscope with unique D-blade. In Hurler’s syndrome, C-MAC with D-blade is an excellent tool in establishing an airway in a pediatric difficult airway scenario. Moreover, D-blade C-MAC could be considered as the primary tool for establishing an airway in pediatric patients with Hurler’s syndrome.

Burn the Bridge to Cross the River? To Paralyze or Not to Paralyze the Pediatric Difficult Airway.

Burn the Bridge to Cross the River? To Paralyze or Not to Paralyze the Pediatric Difficult Airway.

Direct laryngoscopy assisted fiberoptic intubation: A novel technique for the pediatric airway

ObjectiveTo introduce a novel intubation technique for difficult pediatric airways. MethodsThis two-provider technique requires a direct laryngoscope and a flexible fiberoptic laryngoscope. One provider performs direct laryngoscopy which allows for introduction of the flexible laryngoscope. The second provider inserts the flexible laryngoscope with the endotracheal tube loaded, through the oropharynx in to the subglottis. ResultsWe report three pediatric patients that were initially unable to be intubated by conventional methods. We were ultimately able to successfully intubate these patients with difficult airways using our novel technique. ConclusionsWe found that this technique of direct laryngoscopy assisted flexible fiberoptic intubation is a useful adjunct in select pediatric difficult airway patients.

Apnoeic oxygenation in paediatric anaesthesia: a narrative review.

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.