Head extension- External laryngeal pressureOperator:- Landmark cricothyroidmembrane- Stabilize needle- Aspirate as you advance- Advance catheter over needle- Attach syringe and ventilateBurns BJ. Ann Emerg Med 2017Can’t Ventilate, Can’t IntubateSurgical cricothyrotomyAssemble:- Scalpel- Bougie or ETT- Tube or catheterOperator:- Landmark cricothyroid membrane- Make transverse incision through skin andcricothyroid membrane- Insert bougie or ETT and advance- Attach

Pediatric Airway
Management:
Leave the
Cowboy Hat
Behind
Maria J. Mandt, MD
Associate Professor of Pediatrics
Medical Director of EMS
Medical Director Flight For Life, Children’s
Hospital Colorado Team

I have no relevant financial
disclosures
Quality is not an act. It is a habit.
- Aristotle

• Discuss the clinically relevant differences
between the pediatric and adult airways
• Identify predictors of a difficult pediatric
airway
• Formulate a plan in the event of an
unanticipated difficult pediatric
intubation
Time to Talk Objectives, Cowboy
Photo credit: www.theredlist.com

Low incidence, high risk. . .
CCT intubation statistics:
• 1.3% of trips involve peds/neo intubation
• Difficult airway predictors present in 77%
• Neonatal 1st-pass success rate: 59.3%
• Neonatal 1st-pass success without hypoxia or hypotension:
30.8%
• Pediatric 1st-pass success rate: 81.7%
• Pediatric 1st-pass success rate without hypoxia or
hypotension: 60.7%
What should we take away from these numbers?
Burns BJ et al. Ann Emerg Med 2017; Reichert, RJ
et al. Prehosp Emerg Care 2018

Scared now? You Need a Plan
Photo credit:
https://www.youtube.com/watch?v=DwzCrhth090

If you climb in the saddle, be ready
for a ride. . . .
Learn the 7 Ps of
Preparation:
Prior Proper Planning
Prevents Piss Poor
Performance
Photo credit: www.coburgbanks.co.uk

Oh, baby. . . Let
me count the
ways
Critical differences
between the big and
the small

Prominent occiput
Management:
• Shoulder roll for all < 8
years of age
Implication:
• Neck flexion causes UAO
• O/P/L axes not aligned,
making laryngoscopy
difficult
Photo credit: JEMS.com,

Cephalad Larynx
Implication:
• Shorter distance between
tongue and epiglottis
creates acute angle
• Larynx seems more
anterior
Management:
• Optimal positioning
• Gentle cricoid
Photo credit: www.youtube.com/watch?v=EIty86wXmB8

Epiglottis angled over vocal cords
Implication:
More difficult to lift epiglottis and
visualize VC
ETT can get caught on anterior
commissure of VC
Management:
• Gentle cricoid
• Straight blade in
children under 3
Pediatric
Adult

Significant soft tissue and large
tongue
Management:
• OPA
• Lateral approach
to laryngoscopy
Implication:
• Increased risk of
obstruction
• Difficult direct
visualization

Shape of larynx
Management:
• Critical to have
multiple sizes of
ETT
Implication:
• Elliptical shape of
cricoid ring
• ETT may seem
“stuck” just
beyond cords
Harless, J et al. Int J Crit Illn Inj Sci 2014Photo credit: In Coté CJ, Ryan JF, Todres ID, et al [eds]: A
Practice of Anesthesia for Infants and Children.

Physiologic Immaturity
Management:
• Expect rapid desaturation during
apnea
• Early O2, preoxygenation
• Light sedation just prior to
induction can be beneficial
Implication:
• Higher O2 consumption
• Smaller tidal volumes
• Lower FRC
• Higher RR

Predicting difficulty in the
pediatric airway
Incidence of laryngoscopy difficulty in children:
0.1% to 3.5%
• Age < 1 year
• Cardiac anomaly
• Congenital ear malformations
• Cleft palate
• Low BMI
• + usuals
Harless, J et al. Int J Crit Illn Inj Sci 2014

Looks Like
Your Throat
Could Use
Some Plastic:
Preparing for intubation

Considerations Before the
Drugs
• Pre-oxygenation
• Consider nasal cannula for apneic
oxygenation: Low-flow O2 (2-5LPM)
• Consider delayed sequence intubation (DSI)
• Highly anxious children
• Craniofacial abnormalities
• How’s your BMV?

Don’t Be This Guy . . . Creating an Upper
Airway Obstruction

First Learn Stand. Then Learn Fly
• Mental Miyagi Mantra:
“Lift the mask to the
face, Daniel-San”
• 2-person whenever
possible
• Modify the C-E to a “V
clamp”

Considerations Before the Drugs
• Fill the tank
• Head up 20 degrees
• Have the (ever growing)
equipment smorgesboard
available
Weingart SD et al. Ann Emerg Med 2012

Choose Your Weapons!
Growing number of advanced airway options:
• Microcuffed endotracheal tubes
• Supraglottic devices
• Bougie
• Videolaryngoscopy

Cuffed Endotracheal Tubes
Use a cuffed tube whenever possible:
• Uncuffed tube usage leads to excessive tube
exchange rates approaching 30%
• Difficult to predict the correct size with uncuffed
tubes
• No increased adverse event rate with cuffed tubes
• New micro-cuffed tubes have changed the landscape
Crankshaw D, et al. Pediatr Anesth Crit Care J 2014

Microcuff Endotracheal Tubes
• High volume, low pressure: average
11cm H2O
• Short cuff length when inflated and
expands below the sub-glottis
• No change in capnogram
Rameshwar M, et al. Indian J Anaesth 2015
Tube size: Age in years + 3
4
Photo credit:www.richardsmedical.com

Beyond the DL
Have a supraglottic available for
the difficult airway
• 1st choice in 23% of children
with known difficult airway
• High first-pass success and skill
retention rates
• Short insertion times
Jagannathan N, et al. Br J Anaesth 2014;
Hughes C, et al. Pediatr Anaesth 2012
Photo credit:www.remotemedical.com

Beyond the DL
Bougie is an option, but:
• Tracheal rings can be harder to feel
• Smallest Bougie is 10F, fits over
3.5mm tube
• Need 2 people
Photo credit:www.bay-medical.com

VL in Pediatrics
• Improves laryngoscopic
view in the anticipated
difficult airway
• Faster time to successful
ETI in difficult or after
failed ETI
• Higher first-pass success in
those with little intubating
experience
Pros: Not So Pros:
De. Jong A, et al. Int Care Med 2014; Abdelgadir IS, et al.
Cochrane Data Syst Rev 2017; Sun Y et al. Paediatr Anaesth
2014
• Same hypoxia, hypotension and
airway trauma rates as with DL
• In the typical airway, no
difference in 1st-pass success
between VL and DL
• Time to intubation prolonged
with VL
• Increased rate of intubation
failure

Cocktails Preferred by Children
• Atropine
• Ketamine
• Etomidate
• Rocuronium vs succinylcholine

Atropine
Consider for :
• < 1year of age
• Septic shock or hypovolemic shock
• Patients < 5 years of age receiving succinylcholine or
any child receiving a second dose of succinylcholine
Who will grumble:
• Neurosurgeons - pupils will be dilated
• Respiratory therapists - prevents bradycardic
response to hypoxemia
Jones P, et al. Ped Crit Care Med 2013; Jones P,
et al. Arch Dis Child 2012

Ketamine
Arguably, the ultimate RSI sedative:
• Rapid onset: 30 seconds IV
• Brief duration: 10-15 minutes IV
• Fantastic safety profile
• Neuroprotective role now shown in children
• Respiratory depression and laryngospasm are
rare and manageable
Bar-Joseph G, et al. J Neurosurg Pediatr 2009; Green
SM et al. Ann Emerg Med 2011

Ketamine
The old contraindications have been
proven false:
• Neuroprotective role now shown in
children
• No clinically significant rise in IOP
• Respiratory depression and
laryngospasm are rare and
manageable
Bar-Joseph G, et al. J Neurosurg Pediatr 2009; Green
SM et al. Ann Emerg Med 2011
No longer brings the
“you horrible person”
face

Etomidate
• Reliably maintains hemodynamics and decreases ICP while
maintaining CPP
• Dose 0.3-0.5mg/kg IV for induction
• Not recommended for sepsis, but significant debate remains:
• Single dose doesn’t change 24-hour cortisol levels (or it
does)
• Decrease in vasopressor therapy requirement when
etomidate used (or increased mortality)
• Risk of adrenal suppression +/- negated with steroid
administration

Paralytics
• Onset 30-60 seconds IV
• Duration 30 minutes
• Serious adverse effects:
few
• Reversal agent available
Rocuronium Succinylcholine
• Onset 30-60 seconds IV
• Duration 4-6 minutes IV
• Serious adverse effects:
multiple
• May be preferred in the
difficult airway

What About the Narcs?
• RSI with opioids in children is generally not
recommended
• Increased risk of hypotension, early
respiratory depression that interferes with
preoxygenation
• Provide analgesia as part of post-intubation
care

What to do about those neos?
• Median success rate is doubled
with premedication, regardless
of experience
• Successfully intubated in half
the time
• Fewer changes in baseline
heart rate
Give ‘em drugs!
Le CN, et al. J Perinatol 2014; Bottor LT Adv
Neonatal Care 2009

Cocktails Preferred by Children
For most RSI circumstances:
• Atropine (if < 1 year), Ketamine, Rocuronium
For neonates > 36 weeks:
• Atropine, Fentanyl, Rocuronium

Common Pediatric Airway
Management Pitfalls
Watch that last
step, it’s a
doozy. . .

Common Airway Management
Pitfalls
1. Late recognition of upper airway obstruction
• Tracheal tug, stridor, snoring
• Paradoxical chest wall movement
• Capnography changes
The solution:
• Visualization
• Improve technique
Karsli C. Can J Anesth 2015

Pitfalls
Understand the critical importance of jaw thrust
(start video on next slide at 5:45)
Video credit: Kalra A, Tufts Medical Ctr Anesthesia Dept

Pitfalls
2. Inadequate sedation/paralytic depth
• Incorrect dosing or failure to redose
• Results in thrashing, breath-holding and partial
obstruction, leading to rapid oxygen desaturation
The solution:
• Ensure correct dosing
• Ensure multiple doses available
• Ensure effect prior to manipulation

Pitfalls
3. Overly aggressive BMV during and before induction
• Leads to gastric insufflation, reducing lung volumes and
increasing the risk of regurgitation
• Worsens TV
The solution:
• 2-person BMV
• Ventilation timer
• Capnograph

Pitfalls
4. Suboptimal glottis visualization
Children have anteriorly placed larynx and angled
The solution:
• External laryngeal manipulation
• Optimize head position
• Insert laryngoscope deeply and withdraw slowly
• Change blade type or size
• High reps
Burns BJ. Ann Emerg Med 2017

The Unanticipated Difficult Airway
This is why you:
• Practice BMV
• Have a supraglottic available
• Have a video laryngoscope
• Carry a bougie
• Have reversal agents
• Secure prior to departure when possible

Can’t Ventilate, Can’t Intubate
Needle cricothyrotomy
preferred in children < 12
years of age
Assemble:
• a syringe half-filled with
saline
• A 14- or 16-guage syringe
• 15-mm adapter from a
tracheal tube

Step 1: Palpate the cricothyroid
membrane: laryngeal prominence
not fully developed in child < 8yoa
Warning: Unless you’re a sharp-
shooter, this is why it is critical to
make needle cric a last resort:
2.6mm x 3mm
Photo Credit: David Low, CHOP,
www.entokey.com

• Insert the catheter (14-16g)
• Aspirate air to confirm
placement
• Attach tracheal tube adapter
• RR 5-6bpm
• Allows further intubation
attempts if appropriate

If spontaneous respirations:
3) IV
extension set
2) 3-way stopcock
4) 14-16g angio
1) O2 extension
tubing

Summary
• Understand the unique anatomical and physiologic
differences in children and you will increase your
chances of success in pediatric airway management
• A thorough mental check for the risk factors of pediatric
airway difficulty should be part of your 7 Ps
• Know your airway toolbox: optimal drugs, techniques
and equipment
• Be an expert at BMV

Maria.Mandt@childrenscolorado.org
So Long, Cowboy

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