difficult air way

7/28/2019 Difficult Air Way

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Pediatric Airway Management

James Y. Choi, M.D.

Associate Professor

Pediatric Anesthesiology

University of Iowa Heath CareIowa City, Iowa

Objectives

Unique aspects of pediatric airway

management

Airway Anatomy

Respiratory Physiology

Routine pediatric airway management

Difficult pediatric airway management


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Pediatric Airway Anatomy

R = 8L

r4

R= airflow resistance

L= length

r= radius = gas viscosity

Smaller airway diameter



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Larynx position

At birth: C1-C4

Adult position: C4-C7

VC with anterior angulation

Prominent arytenoid cartilages

Large occiput



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Pediatric Respiratory Physiology

Pediatric Respiratory Physiology

Resistance to volatile agents

Upper airway muscles very sensitive to the

effects of anesthetic agents

Infant upper airway muscles more sensitive

than that of adult

Frequent upper airway obstruction during

inhalation induction


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Routine Pediatric Airway

Equipments

Masks

Airways

Laryngoscope blades

Correct size, one size up, one size down

Stylet

Circuit & bag

LMA

Emergency drugs in small syringes with needle


Positioning

Bed height

Large occiput

Rolled towel to stabilize head

Rolled towel to elevate shoulder


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Induction

IV

Inhalation

IM


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Difficult Airway Management

Incidence ofunanticipated difficult

pediatric airway is low

Most of the airway difficulties associated

with congenital syndromes

Difficult Airway Syndromes

Pierre-Robin

Treacher-Collins

Goldenhaars

Mucopolysaccharidosis

Downs

Edwards

Freeman-Sheldon

Kenny-Caffey Schwartz-Jampel

Cri du chat


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Anticipated Difficult Airway

Management Direct laryngoscopy

Alternatives to endotracheal intubation

Alternatives to direct laryngoscopy


Management

Alternatives to endotracheal intubation

Mask airway +/- oral airway

LMA


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Anticipated Difficult Intubation

Mask airway +/- oral airway

For short surgeries

Minimally invasive

Does not protect against aspiration

Hands not available


LMA advantages

Technically not difficult

Frees up your hands

Less invasive than intubation

Controlled or spontaneous ventilation

Can be used as the main airway device

Can be used as a conduit to facilitate

fiberoptic intubation


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LMA disadvantages

Does not protect against aspiration

Smaller LMAs can be dislodged easily

Can cause soft tissue trauma


63> 30

52.520-30

4.5210-20

41.55-10

3.51< 5

Largest ETT

(mm ID)

LMA SizeWeight (Kg)


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LMA Preparation

Lubrication

Size

No wrinkles

Partially inflated



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Alternative LMA Insertion methods

Start with the cuff turned 180 degrees

Corkscrew

Start with the LMA on either side of the mouth

Apply steady downward pressure


LMA assisted intubation

Blind

Fastrach

Fiberoptic


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LMA assisted fiberoptic intubation

If the LMA is seated properly, usually very

easy

Equipment

Long straight hemostat

Wire / Tube exchanger

Swivel adaptor

LMA Assisted Fiberoptic Intubation


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Management

Alternatives to direct laryngoscopy

Lighted stylet Light wand

Shikani stylet

Bullard Laryngoscopes

Fiberoptic intubation

Surgical airway Retrograde wire Cricothyroidotomy

Tracheostomy


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Difficulties in Pediatric asleep fiberoptic

intubation

Small size

Unable to use intubating airway

If spontaneous respiration, often has upper airway

obstruction

Shorter time before desaturation

Cephalad VC

Anterior angulation of the VC Prominent arytenoids, long floppy epiglottis


Asleep fiberoptic intubation

Antisialogogue

LMA assisted if possible

Assistant to pull the tongue out of the way

Spontaneous respiration

Adequate anesthetic

Keep it straight and centered

Practice on routine pediatric airways

If difficulty advancing the ETT, turn 90

counterclockwise


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Unexpected Difficult Airway

Management

Do not continue to

do the same thing

and expect a

different result

Unanticipated Difficult Airway

Management

Difficult mask airway

Oral airway

2 person mask airway

Deepen the anesthetic

LMA

Attempt intubation

Awaken the patient

Surgical airway


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Management Unable to intubate

Reestablish mask ventilation

Ensure optimal positioning

Consider using a different blade

LMA

Alternative techniques

Awaken the patient

Surgical Airway


Management

Alternative techniques

Call for help

Have all the airway equipment available

Antisialogogue

Adequate anesthetic

Spontaneous respiration


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ASA Difficult Airway Algorithm

Unexpected Difficult Intubation

Surgical airway

Retrograde wire

Cricothyroidotomy

Tracheostomy


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Surgical Airway

Retrograde wire

Commercial kits available

Alternative equipment

18G IV catheter

Non-flexible tip epidural catheter

May be technically difficult

Cook Retrograde Wire Kit


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Retrograde Wire

Retrograde Wire


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Surgical airway

Cricothyroidotomy

Commercial kits available

Alternative equipment

18G IV catheter

3 cc luerlock syringe

Tube connector from 7.0 mm OETT

Cricothyroidotomy


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Summary

Unique aspects of pediatric airway management

Systematic approach to difficult pediatric airway

management

Small problems add up to a big problem, pay

attention to small details, details, details

Always have a backup plan and a backup plan

to the backup planbefore getting started

difficult air way

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