This document discusses airway evaluation and management techniques for pediatric patients. It begins by outlining key anatomical features to evaluate the airway, including the Mallampati classification. It then covers positioning, bag mask ventilation, and various airway adjuncts like oral/nasal airways. Endotracheal intubation techniques using different blade types are described. The laryngeal mask airway is also discussed as an alternative to intubation. Finally, the document outlines several pediatric conditions associated with difficult airways.

1. Airway Management
Carlos Rodriguez, MD
Assistant Professor
Department of Pediatric Anesthesiology

2. Evaluation of the Airway
 Size of upper incisors
 Relation of the maxillary and mandibular incisors at
mouth closure and with voluntary protrusion of lower
jaw
 Interincisor distance
 Visibility of the uvula
 Shape of the palate
 Thyromental distance
 Hyomental distance
 Length of neck
 Range of motion in the neck and head

3. Mallampati Classification
 Classification developed to grade the size of
the tongue in relation to the size of the oral
cavity
 Phonation FALSELY improves the view
 Class I: soft palate, tonsillar pillars, uvula
 Class II: tonsillar pillars and base of uvula
 Class III: soft palate
 Class IV: hard palate

4. Mallampati Classification
http://www.touchneurology.com/img/Image/Mallampati.gif

5. Positioning for Endotracheal Intubation
 Sniffing Position
 Elevation and extension of the patient’s head
 Goal is to align the oral, pharyngeal, and laryngeal axes
 May not be appropriate for younger patients
 Patient’s face should be near the practitioner’s
xyphoid cartilage
 Shoulder roll or ramp may be indicated
 External auditory meatus/sternal notch alignment

6. Bag Mask Ventilation
 Critical component of airway management
 Provides oxygenation and ventilation before
the placement of an airway
 Create a SEAL!!!!!!
 Use the thumb and index finger to hold the mask
to the face
 Other fingers hold the mandible
 Use jaw thrust to relieve obstruction
 Look for chest rise and fog within mask
 One-person vs Two-person ventilation
technique

7. Bag Mask Ventilation
 Large occiput in the pediatric population
leads to flexion of the neck in the
supine position
 Children have relatively larger tongues
 Leads to obstruction and possibility of
difficulty in ventilation

8. Airway Adjuncts
 Oral Airway
 Relieves obstruction created
by tongue/epiglottis
 Poorly tolerated in lightly
anesthetized patients
 Risk of damage to soft and
hard palate
 Nasal Airway
 Useful in patients after oral
surgery
 Better tolerated in awake
patients/less likely to gag
 Risk of epistaxis
 Contraindicated in patients
with basilar skull fractures
and coagulopathies
http://www.healthsystem.virginia.edu/internet/anesthesiology-elective/airway/equipment.cfm

9. Endotracheal Intubation
 Laryngoscope
 Held with the left hand
 Blade is inserted into the
right side of the mouth
 Blade deflects the tongue
to the left
 Avoid pressure on gums
and teeth
 USE forward and upward
movement
 AVOID lever movement
towards practitioner
http://www.laryngoscopes.net/

10. Endotracheal Intubation
 Miller Blade/Straight
Blade
 The blade passes
the epiglottis
 Elevation of the
epiglottis exposes
the glottic opening

11. Endotracheal Intubation
 Macintosh/Curved
Blade
 The blade is
advanced into the
vallecula
 Forward and upward
movement moves
epiglottis to reveal
glottic opening

12. Endotracheal Intubation
 Tube size is determined according to internal
diameter
 Lengthwise centimeter markings will guide
practitioner of depth placement
 Cuff vs No cuff
 Cuffs facilitate positive pressure ventilation and
help prevent the aspiration of gastric contents
 Appropriate size of tube:
 4 + Age/4 = tube diameter
 Estimate endotracheal length:
 12 + Age/2 = length of tube (in cm)

13. Endotracheal Intubation
 Confirmation of Tube Placement
 Clinical Assessment
 Auscultationof lung fields and over stomach
 Symmetric bilateral movement of chest
 Condensation within the endotracheal tube
 Monitors
 End-TidalCO2
 Pulse Oximetry

14. Endotracheal Intubation
 Glottic Opening
 Grade I: full view
 Grade II: posterior
portion visualized
 Grade III: Only the
tip of the epiglottis is
visible
 Grade IV: Only soft
palate is visible

15. LMA

16. Pediatric/Infant Anatomy
 Large and floppy epiglottis
 May lie against the posterior wall of the
pharynx
 Large tongue relative to the mandible
 Glottis lies higher and more anterior
 Vocal cords are angled more forwards
and downwards

17. LMA: Indications
 Routine Airway Management
 “as long as there is not a contraindication
to the use of the face mask”
 Difficult Airway Management
 Emergency Airway
 Conduit for Intubation

18. LMA: Contraindications
 Do NOT use as a substitute when the airway
MUST be guaranteed
 Reduced pulmonary compliance
 Patients with certain oral and periglottic pathology
 Situations when airway cannot be readily accessed
when dislodged
 Full stomach
 Nonfasted persons
 Morbidly obese
 Recent trauma
 GERD
 Intestinal obstruction

19. LMA
 How do we determine the size of LMA a
patient will need?

20. LMA Sizes
Size Weight
1 < 5 kg
1.5 5-10 kg
2 10-20 kg
2.5 20-30 kg
3 30-50 kg
4 50-70 kg
5 > 70 kg

21. Position
 Distal tip above the
esophageal sphincter
 Proximal aspect of
the mask juxtaposed
with the base of the
tongue
 Sides of the mask
facing the pyriform
fossae
 Inflated cuff creates a
low-pressure seal
around the periphery
of the laryngeal inlet

22. What is the optimal Cuff
Pressure?
 Recurrent laryngeal nerve injury
 Distorted pharyngeal anatomy- reduced
mucosal perfusion
 Postop stridor
 Sore throat and dysphagia
 Manufacturers recommend pressures
lower that 60 cmH2O

23. 40 cmH2O
 Schloss, et all- 2012
 >40cmH2O
 Sore throat
 Less efficient ventilation
 <40cmH2O
 Lower pressures lead to a better seal-
better to conform to the surrounding
hypopharynx
 Small inflation volumes can lead to
substantial increases in intracuff pressures

24. Laryngeal Mask Airway
 Alternative to
tracheal intubation
 Difficult Airway
Algorithm
 Placed blindly; cuff
is deflated with
opening facing
tongue
 Does not reliably
prevent aspiration of
gastric contents
http://www.anecare.com/Products/images/LMA-brief1.jpg;
http://www.oriontraining.co.uk/images/lma.jpg

25. Anesthesiology 2003; 98:1269 –77

26. The Difficult Airway
 Algorithm originated in 1993
 LMA added to algorithm in 2003
 Definition: “conventionally trained
anesthesiologist experiences difficulty
with intubation, mask ventilation or
both”

27. The Difficult Airway
 Disorders with Associated Airway
Problems
 Achondroplasia
 Arthrogryposis
 Beckwith-Wiedemann syndrome
 Cornelia de Lange syndrome
 Epidermolysis Bullosa
 Goldenhaar syndrome
 Pierre-Robin syndrome

28. The Difficult Airway
 Disorders with Associated Airway
Problems
 Treacher Collins syndrome
 Trisomy 21
 Turner syndrome
 Mucopolysaccharidoses
 Hunter
 Hurler

29. The Difficult Airway

30. The Difficult Airway
 Achondroplasia
 Midfacialhypoplasia
 Small nasal passages
 Small mouth
 Megacephaly
 Difficult mask
 Difficult intubation

31. The Difficult Airway
 Arthrogryposis
 Hypoplastic
mandible
 Cleft palate
 Torticollis
 Difficult intubation

32. The Difficult Airway
 Beckwith-
Widermann
syndrome
 Macroglossia
(smaller with age)
 Difficult intubation

33. The Difficult Airway
 Cornelia de Lange
syndrome
 High arch palate
 Micrognathia
 Large tongue
 Cleft palate
 Short neck
 Difficult intubation

34. The Difficult Airway
 Epidermolysis Bullosa
 Pressure lesions in
mouth and airway
 Possible microstomia
 Postoperative laryngeal
obstruction due to bulla
 Difficult intubation

35. The Difficult Airway

36. The Difficult Airway
 Goldenhaar syndrome
 Hypoplastic zygomatic
arch
 +/- cleft tongue, palate
 T-E fistula
 Macrostomia
 Mandibular hypoplasia
 Cervical spine defects
 Difficult intubation

37. The Difficult Airway
 Pierre-Robin syndrome
 Hypoplastic mandible
 Pseudo-macroglossia
 High arched palate
 Difficult intubation

38. The Difficult Airway

39. The Difficult Airway
 Treacher Collins syndrome
 Malar, mandibular hypoplasia
 Cleft lip
 Choanal atresia
 Macro or microstomia
 Difficult intubation
 Difficult ventilation

40. The Difficult Airway
 Trisomy 21
 Small mouth
 Hypoplastic mandible
 Protruding tongue
 C1-C2 instability
 Possible difficult
intubation and ventilation

41. The Difficult Airway
 Turner syndrome
 Narrow maxilla
 Small mandible
 Short neck
 Difficult intubation

42. The Difficult Airway
 Mucopolysaccharidoses
 Hurler
 Coarse facial features
 Macroglossia
 Short neck
 Tonsillar hypertrophy
 Narrowing of airways
 Difficult intubation