Management Of Pediatric Difficult Airway Research Articles

The role of WhatsApp™ in pediatric difficult airway management: A study from the PeDI Collaborative.

Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI-C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI-C members. Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI-C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI-C WhatsApp™ group. 5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case-sharing 78 (22.2%). The median number of responses to original stems was 9 [2-21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41-1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86-1.45]; p < .0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33-1.40], p < .0016), and clinical case-sharing (regression coefficient 1.2547, 95% CI [0.9401-1.5693] p < .0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice. The PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing.

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.

Nasopharyngeal airway size selection and its implication in the management of pediatric difficult airway.

Nasopharyngeal airway size selection and its implication in the management of pediatric difficult airway.

Comparison of the C-MAC video laryngoscope size 2 Macintosh blade with size 2 C-MAC D-Blade for laryngoscopy and endotracheal intubation in children with simulated cervical spine injury: A prospective randomized crossover study.

Background and Aims:CMAC video laryngoscope size 2 D-Blade has been recently introduced for management of pediatric difficult airway. Our primary outcome was to compare glottic view, intubation time, and ease of intubation with the size 2 Macintosh versus D-Blade of C-MAC video laryngoscope in simulated cervical injury in children.Material and Methods:This randomized crossover study was conducted in a tertiary care hospital of Northern India. Forty children of 4–14 years of age were enrolled in this study. After induction of anesthesia, video laryngoscopy was performed either with size 2 CMAC Macintosh (group M) or D-Blade (group D) with manual in-line stabilization. After removal of the first blade, second video laryngoscopy was performed with the alternative blade. Endotracheal intubation was done with the second laryngoscopy. Best glottic view, time for best glottic view, and difficulty in blade insertion were recorded during both the video laryngoscopies. During second video laryngoscopy, difficulty of tube insertion and time for intubation were noted.Results:The glottic view grade was significantly better in group D compared with the group M (P = 0.0002). Insertion of D-Blade was more difficult than Macintosh blade (P = 0.0007). There was no statistical difference in terms of time for best glottic view in group M and group D (13.40 ± 4.90 vs 13.62 ± 5.60 s) and endotracheal tube insertion time (24.80 ± 7.90 vs 27.90 ± 10.90 s), respectively. Number of intubation attempts was similar in both the groups.Conclusions:Size 2 D-Blade of C-MAC video laryngoscope provided a better glottic view in children with simulated cervical spine injury as compared with CMAC Macintosh blade. Success of intubation, intubation time, and ease of intubation were comparable with both the blades.

Clinical advance in difficult pediatric airway management

Background Management of a pediatric airway can be a challenge for anesthesiologists, especially for anesthesiologists who did not get special pediatric anesthesia training. Up to now, there are new devices designed specifically for use in pediatric airway management. Also, several algorithms and guidelines specific to the pediatric difficult airway management have been suggested. Objective The aim of this article is to describe clinical advances in difficult pediatric airway management, and give key evaluation on the roles of new devices and techniques in the pediatric airway management. Content This article mainly describes challenges of pediatric airway management, management of anticipated and unanticipated difficult pediatric airways, available devices for managing the pediatric airway and extubation of pediatric patients with a difficult airway. Especially, it is emphasized that the management of both the anticipated and unanticipated difficult pediatric airway requires a forethought plan to reduce the risk of complications and to enhance patient safety. Moreover, the controversies of extra-glottic airway devices(EGAD) and alternative devices to direct laryngoscopy in pediatric airway management are elucidated. Trend Although airway management strategies for children, techniques and equipment are significantly improved during the past few years, management of difficult pediatric airway remains a problem associated with significant risks and complications. In the future, more efforts and multicentre studies are still needed to determine the best practices for managing the difficult pediatric airway Key words: Children; Airway management; Tracheal intubation

Cystic Teratoma of Face and Scalp - Management of Difficult Pediatric Airway by Modification of Conventional Technique

Management of pediatric difficult airway has always been a challenge to the anesthesiologist. Effective airway management includes proper assessment of the airway, anticipation of difficulties, good preparation &amp; team work. We present a unique case of 6-week-old infant posted for excision of a large cystic teratoma of face and scalp where the airway was secured effectively by using the retro-molar intubation and modification of conventional technique of ventilation and laryngoscopy.

Airway Management of a Neck-Burned Child with Mc-Grath Series 5 Videolaryngoscope and Gum Elastic Bougie

Background: Anesthetic management of a neck-burned child presents many problems but especially airway difficulties are characteristic. In addition to differences between pediatric and adult airway, concomitant challenges of postburn sternomental contractures may lead to the catastrophic outcomes. Videolaryngoscope is an alternative intubation device which improves laryngeal view and does not require a direct glottic view. Gum elastic bougie is also a well-known and valuable aid for management of difficult intubation. Case Report: We presented a successful airway management of a 10 year old boy underwent post-burn contracture releasing surgery for his neck and left upper extremity with Mc-Grath Series 5 videolaryngoscope and gum elastic bougie. The patient had limitation in neck mobility because of severe burn contracture (patient’s neck was contracted in the flexed position, his chin and lower lip was restrained down to the anterior trunk) with lack of any respiratory disorder. After preoxygenation we administered anaesthesia induction. Mask ventilation was failed because of excessive gas leak. So we inserted laringeal mask airway without significant desaturation. After providing adequate ventilation we administered muscle relaxant. After two unsuccessful attempts we performed intubation with Mc-Grath Series 5 videolaryngoscope and gum elastic bougie. We confirmed correct tube placement via capnograph. Conclusion: Concurent use of Mc-Grath Series 5 videolaryngoscope and gum elastic bougie in management of pediatric difficult airway is suitable as an alternative technique.

Facilitating Endotracheal Intubation in Difficult Cases Using an External Magnet

Difficult airway is conventionally defined as a medical scenario in which a trained examiner faces difficulty in either facemask ventilation or tracheal intubation (1). Unlike difficult intubation, the incidence of difficult mask ventilation in adults is considerable (2, 3). Anesthesiologists and those who practice intubation should be familiar with the management of airway and be able to recognize and identify potentially difficult airways including congenital craniofacial deformities with micrognathia (e.g. Pier Robin, Treacher Collins, Goldenhar's, and Crouzon's syndromes) and metabolic diseases causing the deposition of accumulated by-products (e.g., Hurler's, Morquio's, and Beckwith-Wiedemann syndromes). Cormack and Lehane grades 3 and 4 at laryngoscopy are an indication for advanced techniques for intubation. Laryngeal mask airway (LMA) and fiberscope with a directable tip are useful and important modalities in handling difficult airway and intubation (5). Even normal pediatric airway could become critical due to the anatomical and physiological differences between pediatric and adult airway; this particularly becomes a concern in infants, i.e. children younger than one year old. This hazard is augmented in the presence of congenital or acquired difficulties affecting airway. Consequently, proper preoperative assessment is considered as the cornerstone of pediatric difficult airway management. Every anesthetic plan should be tailored according to patients considering the scenario and also the expertise of the practitioner. Opting for spontaneous respiration maintenance and intervening in a step-wise manner are strongly suggested (6) . Multiple airway devices have been and are developed that all of which can be placed under direct vision or blindly; most of these devices consistently both provide and maintain safe oxygenation and ventilation. Furthermore, a wide range of ancillary devices have also been introduced to be of assistance in the management of difficult airway; most of them are available in varied sizes suitable for use in children and incorporate a variety of different types of endotracheal tubes, supraglottic devices, fiber-optic, video, optical, and mechanical technologies. Some of these devices (e.g. video laryngoscope) are expensive and not suitable for developing countries with limited financial reserve; some others need high levels of experiences or learning courses which is not possible for anesthesiologist that are not working in university hospitals or are less experienced. Some of these devices cannot be used in small children or neonates. Therefore, we were encouraged to look for a device that is easy to use and carry, inexpensive, small in size, and available in all sizes for children, and also does not need special training.

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

First International Congress of Airway Management and Anesthesia in Head and Neck Surgery, Tehran, Iran, May 20–22, 2009

Safe oral to nasal tube exchange using the fiberoptic bronchoscope in management of pediatric difficult airway

Safe oral to nasal tube exchange using the fiberoptic bronchoscope in management of pediatric difficult airway