Managing the Difficult Pediatric Airway


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Managing the Difficult Pediatric Airway

  1. 1. Perioperioperative Cardiac Arrest Managing the Difficult Pediatric Airway Jerrold Lerman BASc, MD, FRCPC, FANZCA Clinical Professor of Anesthesiology Children’s Hospital of Buffalo SUNY, Buffalo and Strong Memorial Hospital, University of Rochester, Rochester, NY Bhanankar SM, et al Anesth Analg 2007:105;344 Definitions Difficult Pediatric Airway American Society of Anesthesiologists: • Difficult airway: the existence of clinical factors that complicate either ventilation administered by face mask or intubation performed by experienced and skilled clinicians. Considerations: • Recognize a difficult • Difficult ventilation: inability of a trained anesthetist to maintain SaO 2 >90% via face mask for ventilation and 100% airway inspired oxygen, provided lungs could be oxygenated • Manage a difficult previously airway • Difficult intubation: need for more than three intubation attempts or attempts that last >10 min Cannot ventilate, cannot Intubate may be a fatal combination! Difficult Pediatric Airway Considerations: • How do we assess the airway? • Which airway anomalies are possible? • Which type of airway is required? • How can we maintain and secure the airway? 1
  2. 2. Anatomy of the Larynx Difficult Pediatric Airway Difficult Pediatric Airway Assessment includes: • History Regarding a • Observation: difficult pediatric • AP and lateral views of head and neck airway, in most • Maneuvers: instances, what • Maximum mouth opening • Extend the neck & look at the wall behind you see is what • Flex neck touching chin to chest you get! • Investigations: • Radiology Mallampati classification for Difficult Pediatric Airway grading airways Considerations • How do we assess the airway? • Which airway anomalies are possible? • Which type of airway is required? • How can we maintain and secure the airway? Reynolds, S. F. et al. Chest 2005;127:1397-1412 This classification holds no validity in children! 2
  3. 3. Position for laryngoscopy: Difficult Pediatric Airway left lateral decubitus Anatomical features of a "difficult airway": • Skull/CNS anomalies • Inability to flex/extend the neck • TM joint dysfunction • Maxillary hypoplasia • Retro or micrognathia (with glossoptosis) • Microstomia • Soft tissues: • limitation of movement • mass effect • Laryngeal/glottic anomalies MASK ANESTHESIA! ! Pierre Robin Sequence Clark DA. Atlas of Neonatology WB Saunders, Philadelphia, 2000 First Arch Syndrome Whistling Face Syndrome Branchial Arches 3
  4. 4. Cleft Lip & Palate Cleft Lip and Palate Treacher-Collins Age Complexity of Defect Presence of micrognathia: yes - 50%, no - 3.8% Xue FS, et al Ped Anesth 2006:16;283 4
  5. 5. Hemifacial Microsomia Otomandibular dysostosis: • spectrum of defects (OMENS classification) • first and second branchial arches and first cleft • increasing airway difficulty with increasing complexity from unilateral to bilateral • mandibular hypoplasia/ TM jt dysostosis • auricular defects • facial nerve defects... • Goldenhar’s syndrome • also vertebral (40%), CHD (35%) Hemifacial Microsomia HemiFacial Microsomia Characteristics: • 1:3500 to 27,000 live births Unilateral HFM Bilateral HFM • Radiographics: • Unilateral or bilateral • Three airway defects: • Type I: Mini-mandible • Type 2: Abnormal condyle • Type 3: Absent ramus, condyle, TM jt • Difficulty with intubation: • All patients with Type 1 were easy airways • 25% of those with Type 3 were very difficult • With bilateral HFM: 1/3:1/3:1/3 easy, difficult, very difficult Nargozian C, et al. Nargozian C, et al. Ped Anesth 1999:9;393 Ped Anesth 1999:9;393 Where are the cords? Press on the chest and look for a bubble 5
  6. 6. Laryngeal Web The traumatic airway Ped Anesth 2001:11;615 Difficult Pediatric Airway Canadian Pediatric anesthesiologists prefer inhalational anesthesia to Considerations manage difficult pediatric airways: • How do we assess the airway? a survey • Which airway anomalies are possible? • How do we manage the airway? • >90% prefer inhalational inductions • >50% will use IV anesthesia with a shared airway, no concern • How can we maintain and secure the • >73% will use direct laryngoscopy, add LMA for fiberoptic airway? • Complete airway obstruction: rigid bronchoscopy Brooks P., et al Can J Anesth 2005:52;285 Inhalational Induction The Difficult Pediatric Airway 6
  7. 7. The “Real” Jaw thrust The Jaw Thrust - Partial or Complete Complete Partial Larsen CP Jr., Jr., Larsen CP Anesthesiology 89:1293, 1998 Anesthesiology 89:1293, 1998 Subluxing the TM Joint Unsuitable for inhalational Physiologic effects: anesthetic! • Prevents oropharyngeal obstruction: lifts the tongue off the posterior pharyngeal wall, opens the laryngeal vestibule • Causes intense pain, "fright & flight"…child takes deep breaths, thus opening the vocal cords & obviating laryngospasm • "Shot of epinephrine to the reticular activating system"….wakes the child up at the end of surgery Airway Management Induction of Anesthesia In the normal airway: • Face mask, LMA, oral/nasal tracheal intubation Anesthetic agents: under inhalational anesthesia • Sedation In the difficult airway: • Propofol, midazolam/fentanyl, ketamine If old enough to sedate/local anesthesia, use DL: • Inhalational induction • Glottis visible ⇒ anesthetize, paralyze and intubate trachea • Sevoflurane: mask anesthesia, spontaneous ventilation, • Glottis not visible ⇒ anesthetize and use fiberoptic, light wand, Wu scope etc • IV induction • If too young to sedate, inhalational induction and • Propofol or Ketamine; supplement with midazolam & secure tube quickly fentanyl AIRWAY takes precedence over a full stomach! 7
  8. 8. Neuromuscular Blockade? Neuromuscular Blockade? Considerations: Avoid NMB drugs because: • NEVER paralyze a child with an uncertain • May be unable to ventilate the lungs…suggamadex or difficult airway …unable to ventilate? • Spontaneous ventilation maintains laryngeal muscle • Succinylcholine is the preferred agent tone; negative intra-thoracic pressure, easier to unless… view larynx • Contraindications: Airway difficulty, MH, • Permits wakening the child & regrouping hyperkalemia • Use of the airway devices: LMA, lightwand, • Rocuronium is a poor second choice… fiberoptic bronchoscope etc. • Contraindicated with airway difficulty • Cannot be reversed easily…Sugammadex! Difficult Pediatric Airway Airway management Considerations: Techniques: • How do we assess the airway? • Direct laryngoscopy with a stylette • LMA • Which airway anomalies are possible? • Fiberoptic scope • Which type of airway is required? • Bullard • How can we maintain and secure the • Lightwand airway? • Glidescope • Surgical airway Paraglossal (molar) approach Equipment Henderson J. Anaesthesia 1997:52;552 Courtesy of Dr. Berkowitz, U of R 8
  9. 9. Two person intubation technique Stylette the ETT Lerman J, Creighton RE. Ped Anesth 2005:16;96 Emergence & Extubation In children: • Plan for an awake extubation (Desflurane) • Awake requires return of gag reflex, responsive and purposeful, regular respiration Difficult Airway? • 100% oxygen • THERE IS NO ROOM FOR PREMATURE EXTUBATION! • Laryngospasm in a child with a difficult airway could be a disaster 9