Pediatric Airway Management Research Articles

Assessing institutional pediatric airway emergency readiness: key components and practices.

This contemporary review aims to outline the key components and protocols for assessing emergency readiness in institutional pediatric airway management. Emphasis is placed on identifying essential elements that ensure preparedness and effective response in pediatric airway emergencies within healthcare institutions. Recent studies highlight several critical components of pediatric airway emergency readiness: dedicated pediatric airway teams, availability of specialized pediatric airway equipment, and simulation-based training to enhance the skills of healthcare providers. Additionally, interdisciplinary team coordination and regular drills have been shown to improve readiness and outcomes in pediatric airway emergencies. Effective emergency readiness in pediatric airway management requires a multifaceted approach. Key components include availability of appropriate and accessible equipment, adherence to standardized protocols, and ongoing education and training. Regular simulation exercises and interprofessional collaboration are essential for maintaining high levels of preparedness. Implementing these strategies can significantly improve the quality of care and patient outcomes in pediatric airway emergencies. Level 3.

Improving airway management in pediatric emergency intubation: A narrative review with a focus on bougie guidance in settings with limited resources

AbstractBackgroundEffective airway management in pediatric emergency settings, especially in resource‐limited environments, presents unique challenges that necessitate innovative solutions.ObjectivesThis review investigates the role of bougie‐guided pediatric intubation as a crucial technique in addressing these challenges.MethodsA comprehensive search of peer‐reviewed literature was conducted using reputable databases such as PubMed, Scopus, Google Scholar, and Web of Science. Suitable keywords and Medical Subject Headings terms were employed. Data extraction focused on study design, patient demographics, intervention protocols, primary outcomes, and safety profiles. A qualitative synthesis was performed to provide a comprehensive narrative review.ResultsPediatric bougies, known for their cost‐effectiveness and adaptability, emerge as promising tools for successful and efficient pediatric intubation. Comparative studies indicate that bougie use results in superior first‐pass success rates and reduced intubation times. Case studies highlight the bougie's versatility in managing difficult pediatric airways.ConclusionsThe bougie's cost‐effectiveness positions it as a practical solution to disparities in treatment levels. Successful pediatric intubation in resource‐limited settings requires improved accessibility, standardized proficiency, and infrastructure readiness. Integrating the bougie into pediatric airway management guidelines represents a proactive approach to these challenges.

The Epidemiology of Out-of-Hospital Pediatric Airway Management in the 2019 ESO Data Collaborative

Objectives Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set. Methods We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, noninvasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA. Results Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%. Conclusions In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.

A challenging Paediatric Airway Management; Acquired Tracheo-oesophageal Fistula Following Accidental Ingestion of a Metal Bobbin

Acquired trachea-esophageal fistula formation is a rare, life-threatening complication of delayed presentation of foreign body ingestion. Airway management of such a patient is a significant challenge to the anaesthetist due to air leak from the defect leading to difficult oxygenation and ventilation and gastric insufflation. The paediatric age group adds to the difficulty because of small airway caliber and difficult lung isolation.Multidisciplinary team involvement and close communication, prior imaging to identify the anatomy, and planning were vital for successful outcome.

Pediatric airway management: A narrative review of the current practices and challenges

Pediatric patients are more susceptible to critical events, the management of their airway necessitates skilled and meticulous interventions. Thus, it is essential to be well versed with the knowledge that can aid in our understanding of the pediatric airway. We conducted a narrative review of the current understanding of pediatric airway assessment techniques, various airway adjuncts and devices, the use of video laryngoscopes for endotracheal intubation and future trends. The databases Ovid, Medline, PubMed, Web of Science, and Google Scholar were searched regarding various aspects of pediatric airway management from 2005 to 2024. The search terms were pediatric or infant difficult airway, pediatric difficult airway, apneic oxygenation, and pediatric airway assessment. One hundred articles were deemed relevant by abstract, and their full text was obtained and examined further for compliance, and finally, 40 full-text articles were included in the study. This article discusses the various challenges of pediatric anesthesia related to airway management, emphasizing the need for individualized perioperative methods due to children’s unique anatomical and physiological features.

Pediatric Difficult Airway Management: Assessment and Intervention

Background: Pediatric airways exemplify the adage that children are not merely small adults. Their airway anatomical differences are markedly different than that of an adult system and with evidently variable physiology. Small fully oxygenated children can desaturate to a level of 0 in by multitudes faster rate than a full-size adult. Narrowing of an airway vastly changes resistance flows in comparison to adults leading to greater volatility and fluidity of an airway status. The airway may be difficult to visually examine or obtain either through innate challenges given its differing height and anterior displacement, or due to additional factors including clefts, congenital changes, stenoses, or mandibular hypoplasia. Rapid and efficient evaluation of the airway for appropriate airway securement involves coordination of different experts and specialized equipment. Otolaryngology is often not involved until difficult situations are deemed untenable with intensive care or anesthesia. Enabling appropriate resource access and timeliness allows for improved patient care and time allocation. At the Children’s Hospital of Michigan, the operating rooms hold the vast number of specific airway equipment needed for pediatric airway evaluation and intervention escalation. This equipment is not centralized and is stored in a multitude of locations, the reliability of which is dependent on stocking experience. Multiple airway emergencies had occurred over several years. These resulted in unsatisfactory outcomes despite prompt responses, appropriate staffing, and decision making. Efforts were centralized in a means to assess access and expediency of airway management with progression to the current system. Methods: Root cause analysis was performed of the reported sentinel airway events. Anesthesia, Emergency Department, and Otolaryngology teams assessed cases for areas of potential failure and improvement. Equipment availability and readiness efficiency were deemed one of the most variable. Additionally, knowledge of predeterminate difficult airways and associated details was deemed vital to allow for appropriate planning and intervention enaction. A multidisciplinary team was tasked with creating centralized difficulty airway carts. These were then stocked with means of airways assessment and intervention within a centralized unit. Communication was enhanced with the creation of automated difficult airway warnings within the electronic health record. A standardized difficult airway note was then created to allow for quick and accessible means of reviewing prior airway assessments. Results: This system has now been implanted within the Children’s Hospital of Michigan. Airway response readiness has improved and multiple emergent airways have been attended and with successful intervention. Handoff of difficult airway informatics has improved with greater understanding between disciplines regarding necessary interventions, precautions, and escalation algorithms. Conclusion: A centralized system of airway assessment and intervention aids in pediatric airway management. Standardized means of communicating airway difficulty improves communication and patient handoffs.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY) Study: Secondary Workload and Provider Outcomes in a Simulation-Based Trial.

An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use. Simulation-based randomized trial, conducted from May to December 2021. Four pediatric simulation centers. Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales. A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand ( p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales ( p < 0.05). The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.

A prospective randomized comparative trial of pediatric C-MAC D-blade video laryngoscope with McCoy direct laryngoscope for intubation in children posted for elective surgical procedures under general anesthesia.

Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C-MAC D-blade compared to the McCoy direct laryngoscope. After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4-12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C-MAC video laryngoscope size 2 D-blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack-Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes. Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C-MAC (0 [0-0] vs. 0 [0-2], p = .055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p = .002), and the time to best glottic view (6 s [5-7] vs. 8.0 s [6-10], p = .006) was lesser in the C-MAC D-blade group while the total duration of intubation was comparable (20 s [16-22] vs. 18 s [15-22], p = .374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications. The C-MAC video laryngoscope size 2 D-blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C-MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D-blade.

To assess the ease of intubation and post-extubation complications of the airway due to the use of microcuffed endotracheal tubes and uncuffed endotracheal tubes

Introduction. Pediatric airway management poses unique challenges due to anatomical differences from adults, rendering children more susceptible to airway complications. Historically, uncuffed endotracheal tubes (ETTs) were preferred in pediatric intubation to minimize risks, but microcuffed (low volume, low pressure) ETTs offer advantages including improved seal and better ventilation efficiency. This study aims to compare the ease of intubation and post-operative airway complications between microcuffed and uncuffed ETTs. Aim. To assess the ease of intubation and post-extubation complications of the airway due to the use of microcuffed endotracheal tubes and uncuffed endotracheal tubes. Methodology. An observational study was conducted on pediatric patients aged 0-10 years undergoing elective surgeries under general anesthesia. Convenience sampling was used to select 54 participants. Patients were divided into two groups: uncuffed endotracheal tube (UG) and cuffed endotracheal tube (CG). Data on intubation attempts and post-operative complications were collected. Results. Baseline characteristics including age, gender, weight, and ASA grade were comparable between groups. Single-attempt intubation success was higher in the uncuffed group (55.6%) compared to the cuffed group (40.7%). Post-operative complications such as respiratory distress, stridor, hypoxemia, and restlessness were more prevalent in the uncuffed group but not statistically significant. Conclusion. This observational study suggests fewer postoperative complications with cuffed endotracheal tube insertion in pediatric patients. However, more research is needed to confirm these findings and explore the efficacy of microcuffed tubes in pediatric anesthesia.

Prehospital mass casualty incident triage simulation builds knowledge and confidence in medical trainees.

Mass casualty incident (MCI) triage simulation is an increasingly useful tool for teaching triage systems to medical students, trainees, and hospital staff. MCI simulation in the prehospital setting has not yet been studied in this population. We aimed to assess the effectiveness of a prehospital MCI simulation in medical students, residents, and fellows. Our primary outcome was knowledge of the components of the triage algorithms used in MCI response. Our secondary outcome was each participant's confidence level if required to assist with or lead a MCI response. This was an observational study with pre-post surveys. We recruited 30 medical students, 14 emergency medicine (EM) residents, and four pediatric EM fellows to fill out a survey before and after a 3-h simulation session practicing the START and JumpSTART algorithms on two prehospital MCI scenarios. Overall, all groups demonstrated significant improvement in knowledge of triage colors, information needed to assign a triage color, pediatric airway management during a MCI, and indications for breaths-first CPR. They also demonstrated significant increase in confidence both in assisting with and in leading a MCI response. Simulated practice triaging patients in prehospital MCI scenarios improves knowledge of triage algorithms and increases confidence in assisting with or leading a MCI response in medical trainees.

Current trends in emergency airway management: a clinical review.

Airway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical spaces. A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.

Temporomandibular joint ankylosis - An anesthesiologist’s nightmare: Case series

Temporomandibular joint (TMJ) ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth. Airway management is a grueling task and has confronted anesthesiologists ever since. The challenge is even more exaggerated when it is a pediatric patient. We present a case series of five pediatric patients with TMJ ankylosis with age 7 years or less, who were posted for its corrective surgery. Although all patients belonged to the pediatric age group, the challenges faced and techniques employed to overcome them were different partly because of different age groups and partly the nature of the airway, with tailoring of each technique accordingly. Pediatric airway management is no less than waging a war as all necessary skills and expertise are put to the test. It combines fortuity with skills. We have to be prepared for the worst in any unforeseen scenario.

Fixation errors in prehospital pediatric airway and breathing management

Fixation errors in prehospital pediatric airway and breathing management

Demonstrating the safety profile of ketamine as procedural conscious sedation in infants; a prospective cohort study of 904 cases

Background: Conscious sedation has both a sedative and an analgesic effect. Ketamine is an increasingly popular choice for procedural conscious sedation in a paediatric day surgery. Ketamine is also cheaper than general anaesthetic. The objective of our study is to investigate the number of adverse events when using ketamine for procedural conscious sedation and demonstrate its safety profile for use in paediatric day surgery in a community setting in infants. Methods: A single-centre, single surgeon, single procedure 5-year longitudinal prospective review of 904 infants undergoing elective day-care surgery using ketamine for procedural conscious sedation between 2016 and 2020. Patients were stratified for pre-anaesthetic co-morbidities based on the American Society of Anesthesiologists (ASA) classification system. Results: All patients were between 4 weeks and 1 year and 98.7% were ASA Class 1. Most children received ketamine intramuscularly and only one child required additional ketamine to maintain procedural conscious sedation. There were no serious adverse events and there were 27 mild adverse events in 26 patients (2.88% patients). The most common adverse event was hypersalivation, which occurred in 11 infants. Conclusions: Ketamine is a safe drug for procedural conscious sedation and should be considered more for infants undergoing elective day-care surgery provided that all staff conducting procedures have advanced training in paediatric and neonatal airway management and resuscitation.

Recent Advances in Paediatric Airway Management

Paediatric airway management is continuously evolving with the innovation of new devices and techniques. The paediatric airway presents notable anatomical and physiological challenges. The introduction of a wide array of videolaryngoscopes and flexible intubating video endoscopes in paediatric sizes has made airway management safer. In addition, second-generation supraglottic airways are increasingly utilised both independently and as a component of hybrid strategies. The introduction of various paediatric airway adjuncts such as Frova introducer, optical stylets and airway exchange catheters has been a valuable addition. Microcuff tubes have proven to be safe for use even in neonates and infants and reduce the number of endotracheal tube exchanges. Apnoeic oxygenation techniques using transnasal humidified rapid insufflation ventilatory exchange help in preventing desaturation during intubation. Point-of-care ultrasound has a multitude of applications in paediatric airway management and is useful technique for the identification of the cricothyroid membrane and assessment of gastric residual volume. Airway assessment and simulation in combination with three-dimensional printing can serve as useful adjuncts in difficult and complicated airways and help in training and skill development and retention. Artificial intelligence and machine learning are in the nascent stages but are continuously evolving and may revolutionise airway assessment in the near future. This narrative review describes the recent advances in airway devices and techniques that have revolutionised paediatric airway management over the past decade.

Anesthetic Management of a Child with a Bizarre Foreign-body Impaction in the Oral Cavity

Abstract Pediatric airway management can be a challenging task for any anaesthesiologist. A foreign body compromising the airway only adds to the difficulties. Airway management requires skill, expertise and a dynamic approach to ensure patient safety and facilitate a smooth surgical intervention. We present the case of a boy who presented with an unusal foreign body in his airway and the novel techniques applied for airway management.

Nasotracheal intubation in pediatrics: a narrative review.

Nasotracheal intubation (NTI) plays an important role in pediatric airway management, offering advantages in specific situations, such as oral and maxillofacial surgery and situations requiring stable tube positioning. However, compared to adults, NTI in children presents unique challenges owing to anatomical differences and limited space. This limited space, in combination with a large tongue and short mandible, along with large tonsils and adenoids, can complicate intubation. Owing to the short tracheal length in pediatric patients, it is crucial to place the tube at the correct depth to prevent it from being displaced due to neck movements, and causing injury to the glottis. The equipment used for NTI includes different tube types, direct laryngoscopy vs. video laryngoscopy, and fiberoptic bronchoscopy. Considering pediatric anatomy, the advantages of video laryngoscopy have been questioned. Studies comparing different techniques have provided insights into their efficacy. Determining the appropriate size and depth of nasotracheal tubes for pediatric patients remains a challenge. Various formulas based on age, weight, and height have been explored, including the recommendation of depth-mark-based NTI. This review provides a comprehensive overview of NTI in pediatric patients, including the relevant anatomy, equipment, clinical judgment, and possible complications.

Challenging Airway Management in a 5-year-old Male Child with Sublingual Lymphovascular Malformation

ABSTRACT We report a 5-year-old male child with a large lymphovascular malformation of the tongue presenting with signs of airway obstruction scheduled for bleomycin sclerotherapy and tracheostomy. Anesthetic concerns include limited mouth opening, airway obstruction, poor visualization, bleeding, and distorted anatomy, thereby rendering mask ventilation, laryngoscopy, intubation, and possible invasive airway access difficult. While awake airway management options are ideal for difficult airways in general, these techniques may be inapplicable to pediatric patients. Management options are further constrained in resource-limited clinical settings where critical equipment may be unavailable. By conducting a thorough preoperative evaluation and by adopting a multidisciplinary approach to case planning, preparation, and management, a strategy was developed, enabling successful airway management. The use of this approach may facilitate the successful anesthetic management of a difficult pediatric airway in austere clinical environments.

Predictors of Per-Intubation Cardiac Arrest in Pediatrics Patients Presenting to the Emergency Department

INTRODUCTION: Airway management is one of the vital resuscitative procedures undertaken in many critically ill pediatric patients presenting for emergency care. Around (2–33/10,000) of all pediatric patients presenting to the emergency department (ED) require airway protection for various conditions, such as respiratory failure, airway protection, and cardiac arrest 1-3. In children, airway management demands great caution because of their age-related differences in anatomical and physiological characteristics and limited physiological reserves. Rapid sequence intubation (RSI) has become the standard technique to facilitate pediatric emergency airway management. AIM OF STUDY: To determine the risk factors associated with peri-intubation cardiac arrest in pediatric patients presenting to the emergency department. RESULTS: Total 125 patients were recruited with case to control ratio of 1:4. Data was analyzed for demographic, examination, level of training, drug and outcome variables. The median age group was 18months. Among patients who underwent PICA 40% achieved the ROSC. The most common cardiacrhythm was bradycardia. The patients who underwent PICA had raised heart rate and low blood pressure. The hypoxia was found to be significant contributor to PICA. ROC curve applied to values with significant result after regression analysis. CONCLUSION: The major contributor to peri-intubation cardiac arrest is hypoxia OR 8.96 [2.52 -31.88]. Level of training had no significant relation to PICA. SI and MSI were strongly associated with PICA with OR of 3.78 [1.06 -13.52] &amp; 4.93 [1.09 -22.24] respectively.

Comparison of Standard and Lateral Methods of Laryngeal Mask Airway Insertion in the Management of Pediatrics Airway

Background: The Laryngeal Mask Airway (LMA) has traditionally become an alternative device for airway management. This clinical trial compared two standard and lateral techniques in inserting laryngeal masks in pediatric airway management.&#x0D; Methods: This single-blind clinical trial study was conducted on pediatrics aged 2-6 years who were candidates for elective inguinal herniorrhaphy with ASA I and II under general anesthesia. The pediatrics were randomly assigned to either the standard or lateral methods according to the random number table. The time required to insert LMA and airway pressure as well as the number of attempts to insert in both groups were measured. Data analysis was performed using SPSS version 25; the significance level was less than 0.05.&#x0D; Results: Chest movement and mean airway pressure had no significant difference in both groups (p&gt;0.05). The mean LMA insertion time in the lateral and standard methods was 22.94±7.89 and 65±15.27 seconds, respectively (p=0.001). There was no case of mucosal damage in the lateral method, but ten children had mucosal damage in the standard technique (p=0.001). In the lateral method, LMA was inserted for the first time in 32 pediatrics (94.1%) and two pediatrics (5.9%) in the second time but in the standard group, LMA was inserted in the second time in 11 pediatrics (32.4%) (p=0.006).&#x0D; Conclusion: The lateral method for inserting LMA is practically easy, requires less effort, and has the least complications. Another advantage of the lateral method compared to the standard technique is that inserting a finger into the pharyngeal cavity is unnecessary.