1) The document discusses managing difficult pediatric airways, noting assessments that should be done and potential airway anomalies. 2) It describes various techniques that can be used to secure the airway depending on the child's condition, including inhalational induction, fiberoptic intubation, LMAs, and surgical airways if needed. 3) It emphasizes the importance of avoiding neuromuscular blockade in children with uncertain or difficult airways so spontaneous ventilation and regrouping are possible if needed. Maintaining the airway takes priority over other considerations like a full stomach.

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?
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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!
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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
www.scielo.cl/fbpe/img/rcp/v75n1/f1_03.jpg
First Arch Syndrome Whistling Face Syndrome
Branchial Arches
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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
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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
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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
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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!
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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
www.med-worldwide.com
Henderson J.
Anaesthesia 1997:52;552
Courtesy of Dr. Berkowitz, U of R
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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
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