Paediatric airway guidelines ASA 2022 and AIDAA 2016 Difficult airway guidelines Difficult paediatric airway guidelines Paediatric Anaesthesia Anaesthesia

1. Unanticipated Difficult
Paediatric Airway Guidelines
DR. DHIRAJ TAMASKAR

2. SHOWING STARS TO ANAESTHESIOLOGIST IN
BROAD DAYLIGHT

3. DIFFICULT AIRWAY GUIDELINES
The reported incidence of difficult intubation
infants- 0.24%–4.7% and older children- 0.07%–0.7%
ADULT PAEDIATRIC-SPECIFIC
-ASA,
-DAS(UK),
-ANZCA,
-Canadian Royal College of
-AIDAA, and
-Others
-AIDAA,2016
-Polish Society of Anaesthesiology
and Intensive Therapy,
-Polish Society of Neonatology, -
Association of Paediatric
of Great Britain and Ireland &
-ASA in 2022

4. -Challenges with managing the paediatric airway compared to the adult airway
-Narrow margin of safety leading to increased morbidity and mortality
Anatomy
 Large occiput
 Long, omega-shaped epiglottis
 Vocal cords that are angled more anteriorly
 Decreased subglottic diameter and stenosis
 Larger percentage of narrowing of airway with same degree of oedema
 Cone-shaped, cephalad larynx
 Comorbidities encountered in the paediatric age group (Pierre-Robin
sequence, Down syndrome)
PHYSIOLOGY
 High oxygen consumption and reduced FRC
Resource-specific
 Burden of stocking different-sized airway equipment
 Scarcity of highly specialized airway experts in this age group, especially in
resource-limited settings

5. Stepwise approach to the difficult paediatric airway is globally
comparable to adult algorithms.
Some notable differences include-
 Greater emphasis on constant maintenance of oxygenation
(key factor in prevention of rapid hypoxia and subsequent
bradycardia and cardiopulmonary arrest) and
 Switching to the most experienced paediatric anaesthesia
provider after a failed intubation.
(reflects the importance to reduce potential airway
trauma and subsequent oedema, which can result in significant
obstruction in smaller airways).

6. Airway management items

7. AIDAA DIFFICULT PAEDIATRIC
AIRWAY GUIDELINES 2016

8. UNANTICIPATED DIFFICULT FACEMASK VENTILATION
Steps Notes
-Maintain adequate depth of
anaesthesia
-Upper airway is kept patent with chin
lift and jaw thrust during mask
ventilation
-head is maintained in neutral
position for children and use of a
shoulder roll in children <6 months
- 2-person bag mask ventilation
- Rule out laryngospasm
- Gastric decompression
-Ensure that soft tissue is not being
pushed by the fingers holding the
mask
Avoid compressing the external nares
while holding the face mask
- Consider lateral position in the
presence of adenotonsillar
hypertrophy or lingual tonsil or
when mask ventilation is not
improved by other techniques
- Correct sizes of oropharyngeal and
nasopharyngeal airways may be
helpful
- Obese, syndromic and
micrognathic patients
- Avoid inadequate depth
- NM blockers

9. AIDAA DIFFICULT PAEDIATRIC AIRWAY GUIDELINES 2016
CALL FOR HELP

10. - Appropriate laryngoscopy equipments
- Optimal positioning
- External laryngeal manipulation
- Videolaryngoscopes
- Bimanual laryngoscopy
- Intubation aids- malleable stylets, soft gum elastic bougie,
Frova
5Fr 50 cm bougie- neonates and infants,
8 Fr bougie/Frova- up to 5–6 years of age (ETT size 5 mm ID)
11 Fr bougie- children over 6 years of age

14. Unanticipated and Emergency Difficult
PaediatricAirway Guidelines ASA 2022

15. Recommendations for unanticipated
difficult airway
 Call for help.
 Optimize oxygenation.
 When appropriate, refer to an algorithm and/or cognitive aid.
 Upon encountering an unanticipated difficult airway:
• Determine the benefit of waking and/or restoring spontaneous
breathing.
• Determine the benefit of a noninvasive versus invasive approach to
airway management.

16. If a noninvasive approach is selected, identify a preferred sequence of
noninvasive devices to use for airway management.
▪If difficulty is encountered with individual techniques, combination
techniques may be performed.
▪Be aware of the passage of time, the number of attempts, and oxygen
saturation.
▪Provide and test mask ventilation after each attempt, when feasible.
▪Limit the number of attempts at tracheal intubation or supraglottic airway
placement to avoid potential injury and complications.

17. •If an invasive approach to the airway is necessary (i.e., cannot intubate,
cannot ventilate), identify a preferred intervention.
◦Ensure that an invasive airway is performed by an individual trained in
invasive airway techniques, whenever possible.
◦Ensure that an invasive airway is performed as rapidly as possible.
◦If the selected invasive approach fails or is not feasible, identify an alternative
invasive intervention.
▪Initiate ECMO when/if appropriate and available.

20. The airway manager’s assessment and choice of techniques should be based
on-
- Their previous experience;
- available resources, including equipment,
availability and competency of help; and
- the context in which airway management will occur.

21. Pediatric patients may restrict particularly options that involve
awake intubation.
Airway management in the uncooperative or pediatric patient
may require an approach of Intubation attempts after induction
of general anesthesia

23. A. Time out
Time Out for identification of the airway management plan.
A team-based approach with identification of the following is preferred:
-the primary airway manager and backup manager and role assignment,
-the primary equipment and the backup equipment, and the person(s) available to
help.
-Contact an ECMO team/otolaryngologic surgeon if noninvasive airway management
is likely to fail (e.g., congenital high airway obstruction, airway tumor, etc.)

24. B. Color scheme
The colors represent the ability to oxygenate/ventilate:
Green-easy oxygenation/ventilation;
Yellow- difficult or marginal oxygenation/ventilation; and
Red,-impossible oxygenation/ventilation.
Reassess oxygenation/ventilation after each attempt and move to the appropriate box
based on the results of the oxygenation/ventilation check.

25. C. Nonemergency pathway (oxygenation/ventilation adequate)
Deliver oxygen throughout airway management;
Attempt airway management with the technique/device most familiar to the primary airway
manager;
Select from the following devices: supraglottic airway, videolaryngoscopy, flexible
bronchoscopy, or a combination of these devices (e.G., Flexible bronchoscopic intubation
through the supraglottic airway); other techniques (e.G., Lighted stylets or rigid stylets may be
used at the discretion of the clinician);
Optimize and alternate devices as needed;
Reassess ventilation after each attempt;
Limit direct laryngoscopy attempts (e.G., One attempt) with consideration of standard blade
videolaryngoscopy in lieu of direct laryngoscopy;
Limit total attempts (insertion of the intubating device until its removal) by the primary airway
manager (e.G., Three attempts) and one additional attempt by the secondary airway manager;
After four attempts, consider emerging the patient and reversing anesthetic drugs if feasible.
Clinicians may make further attempts if the risks and benefits to the patient favor continued
attempts.

26. D. Marginal/emergency pathway (poor or no
oxygenation/ventilation
treat functional (e.g., airway reflexes with drugs) and anatomical
(mechanical) obstruction;
attempt to improve ventilation with facemask, tracheal intubation, and
supraglottic airway as appropriate;
and if all options fail, declare CICV
consider emerging the patient or using advanced invasive techniques.
(rigid bronchoscopy, emergency invasive techniques, ECMO)

27. E. Team Debrief
Consider after all difficult airway encounters:
 Identify processes that worked well and opportunities for system
improvement and
 Provide emotional support to members of the team, particularly when
there is patient morbidity or mortality

28. Extubation of difficult airway
Includes interventions that may be used to facilitate airway management
associated with extubation of a difficult airway. Extubation intervention
include:
 assessment of patient readiness for extubation,
 the presence of a skilled individual to assist with extubation,
 selection of an appropriate time and location for extubation,
 planning elective tracheostomy,
 awake extubation or awake supraglottic airway removal,
 supplemental oxygen throughout the extubation process, and
 extubation with an airway exchange catheter or supraglottic airway (for
possible reintubation)
The task force regards the concept of an extubation strategy as a logical
extension of the intubation strategy.

29. Follow-up care includes :
(1) post extubation care(i.e., Steroids, racemic epinephrine),
(2) post extubation counseling (i.E., Informing and advising the
patient or responsible individual of the occurrence and potential
complications associated with a difficult airway)
(3) documentation of difficult airway and management in the
medical record and to the patient, and
(4) registration with a difficult airway notification service.

30. AIDAA 2016 • ASA2022
• Continuous nasal oxygenation throughout
• (Maintaining spo2 >95%)
• Menitoned Sequence of use of non-invasive
devices
• Maximum attempts at intubation – 3
• Maximum SAD attempts- 2
• Face mask ventilation with NM blockade- one
attempt
• Age wise invasive airway management
• Supplemental O2 administration before
initiating and throughout difficult airway
management, including the extubation
process.(No mention of cutoff for spo2)
• Recommend to use the device you are most
familiar with
• Attempts total 3+1
• No age wise invasive airway approach
mentioned
• ECMO
• Robust recommendations for extubation of
difficult airway
• Team Debriefing

31. Priority is to maintain ventilation and
oxygenation and not just intubation.
-If intubation attempt fails, DON’T
FORGET TO bag-mask ventilate the
patient and keep the spO2 >95%
-supplemental oxygenation throughout
the procedure

32. KEEP CALM
&
INTUBATE
THANK YOU!