Approach to Difficult and Compromised Airway in Neonatal.pptx
1. Approach to Difficult and
Compromised Airway in
Neonatal and Paediatric Age
Group Patients
Dr Sirisha.G
2. • Management of even normal airway in a
neonate is different and complex as
compared to airway of two year old child and
that of adult.
• The child differs from adult in many ways both
in size, shape and position of airways as well
as in the airway epithelium and its supporting
structures.
3.
4.
5. Pediatric Vs Adult airway
• Airway of infant differs in following ways from
that of adults
• 1. Upper airway of the infant is smaller than
that of adult.
• 2. Relatively large size of infant’s head tends
to flex the short neck and obstruct the airway.
• 3. Relatively large size of infant’s tongue in
relation to oropharynx increases the
likelihood of airway obstruction
6.
7. Pediatric Vs Adult airway
• EPIGLOTTIS-short and stubby in children,
• Angled over laryngeal inlet, control with
laryngoscope blade is difficult
• Blindly passed tube can land up in anterior
commisure rather than slide into trachea
• Infant larynx- FUNNEL shaped- narrowest at
CRICOID-minimal edema of cricoid ring may
reduce airway by 70% in neonate
8. COMPROMISED AIRWAY
• Any partially obstruction to airway that poses
a constant threat to total obstruction.
• May be fatal , require urgent and expert
management to avoid mortality and morbidity
• May result in cerebral hypoxia , permanent
neurological damage or interventricualr
haemorrhage
• Causes of compromised airway can be
acquired or congenital
9. Signs of airway obstruction
• Clinical signs of airway obstruction-
• Stridor
• Intercoastal drawing
• chest recession
• Apneic attacks with intermittent cyanosis
• Bradycardia with peripheral circulatory failure
10. Evaluation of difficult neonatal and
paediatric airway
• History of apnea, stridor, day time sleep, snoring (may be
indicative of airway obstruction, that can be exaggerated by
induction).
• History should also consist of review of previous anaesthetic
records with attention being paid to history of oropharyngeal
injury, damage to teeth, postponement of surgery after
anaesthetic exposure.
Physical examination includes:
• Evaluation of size and shape of head.
• Gross facial features.
• Size and symmetry of mandible.
• Size of tongue.
• Prominence of upper incisors.
• Range of motion in jaw and head and neck.
11. • A number of bed-side tests have been
proposed to assess difficult airway in adults.
• Thyromental distance by Patil and colleagues.
• Visual examination of the posterior wall of
the pharynx by mallampatti.
• But the commonly used assessment criteria
have not been valid for small babies and even
mouth opening, neck and jaw mobility are
difficult to assess in non-cooperative child
12.
13.
14. Hypoxia in a child causes bradycardia!
• Consider bradycardia in a child to be caused by hypoxia
until proven otherwise! Hypoxia in an adult or older child
usually triggers a sympathetic response, producing a
tachycardia that improves oxygen delivery. Bradycardia is
a late and very dangerous sign of imminent cardiovascular
collapse.
• In contrast, bradycardia in babies and young children may
be the first sign of hypoxia—not the last.
• The small child’s immature nervous system has a better
developed parasympathetic nervous system. Babies spend
a lot of time eating and sleeping, and not so much time
engaged in fight-or-flight activities. As a result, hypoxia
triggers a vagal response and slows the heart.
15. • Infants and small children have a cardiac output
that is rate dependent.
• Bradycardia significantly lowers cardiac output
and oxygen delivery; hypoxia and hypercarbia
worsen.
• Acidosis develops, further depressing the
myocardium. Cardiac arrest can occur very
quickly in the hypoxic child and must be treated
urgently with oxygen, ventilation, and if needed,
atropine.
16. Causes of compromised airway
1) Cranio facial anomaly
• Pierre Robin Syndrome
• Treacher Collin’s syndrome
• Goldenhar Syndrome
2) Cervical spine
• Down Syndrome
• Klippel Feil Syndrome
3) Structural
• Mucopolysaccharidosis
• Post burns contracture
• Trauma
• Temporomandibular joint
ankylosis.
18. PIERRE ROBINSON SYNDROME
• It is a rare syndrome with micrognathia and posterior
displacement of tongue (glossoptosis) causing airway
obstruction in the neonate, failure to thrive.
• Other congenital anomalies associated can be cleft palate,
oesophageal atresia and eye problems.
• Oesophageal atresia, eye anomalies and oligohydroamnios
could play a role in mandibular hypoplasia which keeps the
tongue high in the oral cavity causing cleft in the palate by
preventing closure of palatal shelves and causing cleft
palate.
• Mandibular hypoplasia resolves and child obtains normal
profile by 5-6 years of age. These neonates should be
nursed in the prone position
19.
20. MANAGEMENT
• If this fails to relieve the respiratory obstruction
nasopharyngeal airway/endotracheal intubation
should be done to protect the airway.
• If intubation is not possible, tracheostomy may be
done to secure the airway as sometimes even
fiberoptic bronchoscopic intubation can be
unsuccessful because of narrow anatomical
conditions.
• LMA is a good alternative for these type of babies.
These babies may need surgery for tongue tie or cleft
palatal repair. Inhalational induction with spontaneous
breathing is the suitable method to secure the airway.
23. MANAGEMENT
• Anticipate difficult mask ventilation due to multilevel upper airway obstruction
– Nasopharyngeal airways (NPA), oropharyngeal airways (OPA)
– Supraglottic airways (SGA)
– Two experienced providers for bag-mask ventilation
• Anticipate difficult direct laryngoscopic view
– Fiberoptic bronchoscope
– Videolaryngoscope
– SGA designed to facilitate tracheal intubation (“intubating SGA”)
• Anticipate cannot-intubate, cannot-ventilate scenario
– Discuss with ENT surgeons as appropriate
– Confirm the availability of an emergency tracheostomy kit
• Intubation
• Apply the pediatric difficult airway algorithm
• Administer supplemental oxygen throughout the intubation attempt
• Limit the number of intubation attempts
• Ensure eye protection during a possibly lengthy intubation process and
throughout the surgical procedure
• Develop an extubation plan
•
24.
25. Goldenhar syndrome
• It is a rare (1 in every 3500 to 1 in 5600 live births)
• Compromised and difficult congenital hemicraniofacial
dysmorphology and is often associated with difficult
intubation.
• A distorted face is a reliable guide to the potential of
airway problems. The aetiology remains unclear.
• Development defects of first and second branchial
arches during foetal development causes such type of
deformity.
• Intubation at the time of anaesthesia can be difficult
because of combination of a small, asymetric jaw and
limited neck motion.
26.
27.
28. Mucopolysaccharidosis
• MPS are hereditary progressive disorders caused by
excessive intra lysosomal accumulation of
glycosaminoglycans in various tissues.
• The intracellular accumulation of glycosaminoglycans
causes cellular enlargement with resultant disruption
of the structure and functions of tissue involved.
• Multiple factors are present in MPS which make airway
management and tracheal intubation potentially
hazardous.
• In addition to generalised infiltration and thickening
of soft tissue, oropharynx may be obstructed by large
tongue with or without tonsillar hypertrophy.
29.
30. MUCOPOLYSACCHARIDOSIS
• The nasal airway is also narrowed by thickened mucous
membrane, adenoid hypertrophy and reduntant
granulomatous tissue.
• Neck is typically short, immobile. Cervical spine and
TM joint may have limited range of movement.
• Trachea is often narrow and flattened.
• The uniqueness of the airway and extreme sensitive
airway often result in failure of intubation and
bronchospasm even after successful intubation. The
older the patient greater are the problems due to
progressive nature of disease
31. BURNS
• Burns of the head and neck area and inhalation
burn injuries may cause severe airway
compromise due to massive oedema1
• 2. Best course of action is to intubate and
ventilate without delay.
• Later complications of burn injuries include
hypertrophic scars and contractures.
• Neck contractures make airway, further difficult
as it impairs neck extension thus make glottic
visualization difficult.
32. • Assisted spontaneous
ventilation till the intubation
is possible.
• Maintaining spontaneous
gas exchange benefits in two
ways:
• a. Protects against total
airway obstruction due to
loss of upper airway muscle
tone.
• b. Spontaneous breath
sounds may act as valuable
guide to locate the glottis.
33. Severe burns making the airway compromised and a
case of difficult intubation
34. RETROPHARYNGEAL ABSCESS
• Retropharyngeal abscess It is postentially life threatening condition
as rupture of abscess can result in pulmonary aspiration and under
anaesthesia,
• inability to secure the airway due to blood, pus and secretions.
Baby may not have symptoms of airway obstruction in awake state
but can manifest under anaesthesia with muscle relaxation.
• Thus inhalation induction of anaesthesia should be the right choice
in spontaneously breathing baby.
• Head low position with lateral tilt and use of transparent mask are
helpful to detect and prevent aspiration during intubation.
• Even inability to ventilate inspite of securing airway under direct
vision can cause unforeseen challenges.
• The surgical airway should always be kept ready which can be life
saving in such circumstances.
35.
36. Laryngeal papilloma
• Papillomas of larynx are benign, warty growth that are
difficult to treat Laryngeal papillomas, the most common
laryngeal neoplasm in children.
• Human papilloma virus 6,11,16 have been implicated as
the causative agent.
• A substantial percentage of mother of babies with
laryngeal papillomas have history of genital condyloma.
• At the time of delivery this virus may be acquired by the
baby during passage through the infected birth canal.
• After age at onset is 2-4 years, babies develop hoarseness,
croupy cough, stridor that may lead to fatal airway
obstruction.
• Diagnosis is confirmed by direct laryngoscopy.
37.
38. • Management involves relieving the airway obstruction
by surgical removal of the lesion.
• Tracheostomy is necessary when life threatening
obstruction occurs.
• Various surgical procedures have been used to treat
papillomas but recurrences are the rule and
frequently reoperation may be needed.
• The lesions spread down the trachea and bronchii,
thereby making surgical removal more difficult.
• Fortunately spontaneous remissions do occur usually
by puberty, so that goal of therapy is to maintain an
adequate airway until remission occurs.
39. Cystic Hygroma
• It is benign cystic hamartoma of lymphatic
system. Multiple cystic cavities filled with clear
and straw coloured fluid.
• Majority of hygroma do not cause intubation
difficulty, some times may become difficult to
intubate that may require tracheostomy
40.
41. OCCIPITAL ENCEPHALOCELE
• It is a neural tube deformity related to anancephaly
and spina bifida.
• The cranial defects occur 1/10th as commonly as the
spinal ones and are associated with circular/oval
defects in the occipital bone.
• The lesions may very from quite small skin covered
nodule to very large cystic swelling bigger than the
neonate’s head.
• The covering is sometimes quiet thin, being on the
verge of rupture. Both types usually contain brain
tissue, either cerebellum or part of occipital lobe and
are frequently associated with microcephaly
42. OCCIPITAL ENCEPHALOCELE
• Associated common congenital
anomalies are:
• 1. Myelomeningocele
• 2. Klippel-Feil abnormality
• 3. Congenital heart disease
• 4. Duodenal atresia
• 5. Anorectal malformation
• 6. Cystic disease of kidney and pancreas
• 7. Klippel Feil abnormality produces
intubation difficulty
• The presence of huge occipital
encephalocele adds to intubation
difficulty.
• Laryngoscopy, intubation and airway
management, become difficult in the
supine position due to large occipital
encephalocele
43. • Awake intubation in the right lateral position
can be done to overcome the problem
• Since awake intubation has the advantage
that neonate’s airway tone, reflexes and
respiratory efforts are maintained if
laryngoscopy and intubation fails.
44. Choanal atresia
• Choanal atresia is a congenital malformation in which
there is no connection between nasal cavity and
aerodigestive tract
• It occurs in 1:7000 births with unilateral to bilateral is 2:1.
• Babies with unilateral atresia have minimal symptoms that
can go undiagnosed for months or years.
• The most common complaint is intractable unilateral
anterior nasal discharge.
• Babies with bilateral choanal atresia present with acute
respiratory distress.
• Distress can be attenuated if the mouth is kept open with
the oral airway strapped in place. 50% of cases are
associated with CHARGE syndrome
46. MANAGEMENT
• A number of surgical procedure have been described for correction
of choanal atresia including endoscopic, transnasal, transseptal and
transalatal approach.
• The anaesthetic approach,
• includes intravenous induction with muscle relaxant of
intermediate duration
• endotracheal intubation
• maintainence with inhalational agents
• Splints made from endotracheal tubes are inserted into each nostril
and fixed in position with a heavy nylon tie around the nasal
septum.
• They are left in position for six weeks to provide patent nasal
airway. The infant should be observed closely in the intensive care
unit with appropriate monitoring until breathing dynamics have
become normal.
47. Sub glottic stenosis
• Sub glottic stenosis can be congenital or acquired.
• Incidence of congenital is 5%, the remaining cases are acquired.
• Acquired subglottic stenosis results from intubation trauma leading to stenosis.
• Significant contributory factors include prematurity, size and amount of movement
of endotracheal tube, duration of intubation, laryngeal or tracheal injury during
intubation and presence of infection during the course of tracheal intubation.
• The clinical presentation may vary from total asymptomatic to typical picture of
severe upper airway obstruction.
• Patients with signs of stridor who repeatedly fail extubation are likely to have sub
glottic stenosis.
• As with other conditions, diagnosis is made by direct laryngoscopy and
bronchoscopy.
• Tracheostomy is performed if in addition to subglottic stenosis, there is glottic or
tracheal involvement. Surgical intervention is ultimately required to correct the
stenosis.
48.
49. Malacia of airways
• Layngo tracheo or bronchomalacia exist when the cartilaginous
framework of the airway is inadequate to maintain the airway
patency.
• Caused by lack of neural control of laryngeal muscles.
• Because cartilage of the infant airway is normally soft, all infants
may have some degree of dynamic collapse of central airway.
• The congenital variety may be isolated or associated with another
developmental defect e.g. tracheo oesophageal fistula or vascular
ring.
• It may be localized to a part of trachea or more commonly may
involve entire trachea as well as remainder of the conducting
airways. In severe cases, cartilage in the involved area may be
missing or under developed.
52. • In severe cases, cartilage in the involved area may be missing or
under developed.
• The acquired variety has been associated with long term
ventilation of premature new borns due to chronic tracheal injury.
• Babies with tracheomalacia present with wheeze, a prolonged
expiratory phase and croupy cough, all of which increase with
agitation and upper respiratory tract infections.
• Diagnosis is confirmed by bronchoscopy.
• Barium swallow may be indicated to rule out co-existing conditions.
No treatment is usually indicated for the isolated condition which
generally improves over time.
• Coexisting lesions such as TOF and vascular signs need primary
repair.
53. LUDWIG’S ANGINA
• It is rapidly progressive cellulitis of the submandibular
space that can cause airway obstruction and death.
• Visualization of glottic opening is impossible because
of trismus, oedema and distorted anatomy.
• To secure the airway fibreoptic intubation may be
done n awake and unparalysed state as total upper
airway obstruction is a fatal complication.
• At times tracheostomy through cellulitis although not
ideal may be done as a life saving procedure.
54.
55. ACUTE EPIGLOTTITIS
• Acute infectious epiglotitis is a relatively uncommon
but truly life threatening disease of the childhood.
• Acute bacterial infection primarily involves
supraglottic structures. Classically, child is sitting up,
dyspneic with mouth open.
• Drooling and drooling resists attempt to lie down.
• Child looks toxic with high fever and tachycardia. The
disease progresses very rapidly and may be fatal with
severe airway obstruction within 6-12 hours, unless,
immediate steps are taken to restore the patient’s
upper airway patency.
56. • As soon as the condition
is diagnosed child should
never be left unattended.
• Management includes
intravenous antibiotics.
Endotracheal intubation
with a smaller tube is
preferred
• Extubation should be
done after 24-48 hours
once direct inspection
shows decrease in the
size of epiglotis.
57. Foreign bodies in the air passages
• These children present enormous challenge to the
anaesthetist.
• The problems are of small size of the airways and
competition for an airway control and compromised
ventilation due to instrument, spasm, bleeding,
laryngomalacia and loosened foreign body.
• There is always possibility of bronchospasm,
laryngospasm, cardiac dysrrhythmias due to
instrumentation.
• Care must be taken not to convert partial obstruction
into total obstruction.
60. POST OPERATIVE AFTER ORAL
SURGERY
• Compromise of airway is the greatest risk in the
immediate postoperative period.
• After palate repair, airway is prone to be compromised.
• The oedema of the palatal tissue due to surgery,
malpositioning of mouth gag, venous engorgement of
uvula and tongue interfere with swallowing, thus
bloody sputum can be aspirated.
• Even in vigorous, awake child, extubation may result in
airway obstruction after palate surgery.
• This can be relieved by endotracheal intubation or
establishment
61. • It is again important to remember adequate ventilation
through an endotracheal tube does not ensure the muscle
strength to maintain it.
• Other factors responsible for making the airway
compromise in the postoperative period are:
• • Repeated attempts at intubation
• • Change in the body position after intubation
• • Intubation more than 72 hours
• • Surgery on neck
• • Coughing and change in position of head with ETT in
place
• • Time of onset of symptoms varies from immediately after
extubation to a maximum of four hours till baby settles
down i.e. within 24 hours.
62. • Thus babies who are at high risk for developing
post operative stridor should be closely
monitored for at least 3-4 hours postoperatively.
• Management involves minimal handling of baby
and supplemental humidification.
• Nebulized adrenalin is dramatically effective, but
in some babies benefit is transient and symptoms
recur within 2 hours.
• Reintubation with a smaller ETT and nasal CPAP
have a role in cases of persistent obstruction.
63. TRAUMA
• Trauma is the major cause of morbidity and mortality in
children between 1-14 years of age.
• If the baby is crying means airways is clear.
• A quite baby is a baby at risk. One should look for signs of
suprasternal in drawing, paradoxical chest movements,
snoring, gurgling, stridor, agitation, cyanosis.
• 95% of polytrauma victim may have associated cervical
spine injury.
• Indications for advanced airway management include
persisting airway obstruction. Penetrating neck injury, head
and facial injury, chest trauma, apnea and hypoxia.
64.
65.
66. Extubation in a case of difficult airway
is fraught with problems because:
• i. The cause of the difficult airway may still be
present e.g. craniofacial anomaly.
• ii. Surgery may have worsened the situation e.g.
wiring of the jaws.
• iii. Repeated attempts at intubation or use of a
too large ETT could have led to trauma and
laryngeal oedema.
• This markedly increases the airway resistance. So
one should not extubate if there is any doubt
regarding the ability to secure the airway if
needed.
67.
68.
69. TAKE HOME POINTS
• Unique anatomical feature of neonatal upper airway themselves make
laryngoscopy and intubation difficult. The presence of abnormalities
further adds to the difficulty.
• Awake intubation remains the most appropriate technique in these
neonates with anticipated difficult tracheal intubation where rapid
control of airway is essential.
• In all cases of compromised and difficult airway, it is mandatory to
preserve the spontaneous respiration while securing the airway.
• Fiberoptic bronchoscopic intubation is the ideal choice but problem in
our country is of limited availability and needs expertised hands while
handling these neonates.
• LMA is very good alternative in difficult to ventilate babies. At times blind
nasal intubation is also successful. Successful management of neonatal
and paediatric difficult airway is a multifaceted challenge to the
anaesthetist to be approached with caution, requisite preparation and
confidence to face unanticipated problems
