Paediatric difficult airway management: Difference between revisions

Jump to navigation Jump to search

Paediatric difficult airway management (view source)

Revision as of 15:45, 12 February 2023

5,157 bytes added ,  1 year ago
no edit summary
No edit summary
No edit summary
Line 106: Line 106:
management in children. 2012. http://www.apagbi.org.uk/publications/apaguidelines</ref><sup></sup>
management in children. 2012. http://www.apagbi.org.uk/publications/apaguidelines</ref><sup></sup>


== AIRWAY ASSESSMENT ==
Proper airway assessment, proper planning for airway management,
and the use of monitoring are essential basic principles for safe
anaesthesia in children.
Airway assessment may be considered in two parts:
Will facemask ventilation be difficult?
:• A tumour or abnormal face shape may prevent the facemask from
sealing easily over the face.
:• Syndromes associated with midface hypoplasia
:• Children with severe obstructive sleep apnoea (e.g. tonsillar
hypertrophy).
Will intubation be difficult?
Factors that may predict difficult intubation in children include:
:• Mandibular hypoplasia e.g. syndromes such as Pierre Robin
:• Poor mouth opening
:• Obstructive sleep apnoea
:• Stridor
:• Syndromes associated with facial asymmetry. Note ear
abnormalities are often associated (e.g. Goldenhar syndrome).
Various tests and scoring systems have been suggested for use in
adults. Many have a very poor sensitivity and/or specificity and are
not validated in children. However, assessment of the following is
essential. The anaesthetist may need some ingenuity to achieve these
assessments in a small uncooperative child!
:• Mouth opening
:• Range of neck movement
:• Mandibular hypoplasia - micrognathia makes intubation difficult.
Assess the airway by observing the child in side view rather than
from the front.
:• Mandibular hyperplasia - ameloblastoma may cause jaw
protrusion and can make laryngoscopy and intubation difficult
:• Inspection of the oral cavity (e.g. for intraoral masses).
The Mallampati score can be used for older children who are
cooperative. Even though there is no validated scoring system in infants
and young children, the anaesthetist must still make a risk assessment,
and decide on the anticipated difficulty of intubation. This airway
assessment must be documented in the anaesthetic record.<ref>World Health Organisation. Guidelines for Safe Surgery 2009. http://whqlibdoc.
who.int/publications/2009/9789241598552_eng.pdf and http://www.who.int/
patientsafety/safesurgery/en/</ref><sup></sup>
== PLAN FOR AIRWAY MANAGEMENT ==
After airway assessment, a structured plan for airway management
is required before induction of anaesthesia. The plan must consider:
:• Choice of airway e.g. facemask, supraglottic airway device or
tracheal tube
:• Mode of ventilation e.g. spontaneous ventilation or positive
pressure
:• Monitoring e.g. pulse oximeter (minimum); end tidal carbon
dioxide.
Due to a lower functional residual capacity (FRC) and higher
metabolic rate, oxygen saturation falls much faster in infants and
young children than adults. Preoxygenation before induction of
anaesthesia establishes a reservoir of oxygen in the lungs by displacing
nitrogen. This means a patient can remain oxygenated for longer than
otherwise expected, which gives more time to address unexpected
airway problems. Therefore preoxygenation is an important part of the
airway management plan and should form part of normal anaesthetic
practice wherever possible, even in children.
== THE UNEXPECTED DIFFICULT AIRWAY ==
Problems with airway management may be due:
:1. Difficult mask ventilation
:2. Difficult tracheal intubation
:3. Can’t intubate and can’t ventilate (CICV).
The first step is to administer 100% oxygen and call for help. Another
pair of hands is always useful.
The next step is to consider – is this a problem with the equipment or
the patient? All equipment should be checked prior to induction of
anaesthesia to minimise the chance of equipment failure.
===1. Difficult mask ventilation===
A simple algorithm for the management of difficult mask ventilation
is given in Figure 1: Difficult mask ventilation algorithm. http://
www.apagbi.org.uk/sites/default/files/images/APA1-DiffMaskVent-
FINAL.pdf
====Difficult mask ventilation – equipment problems====
Equipment failure should be excluded quickly – check the mask,
circuit, and oxygen supply. Always have a self-inflating bag available
in case of equipment problems.
====Difficult mask ventilation – patient factors====
These can be divided into anatomical or functional problems.
Anatomical problems associated with difficult mask ventilation may
be due to poor head positioning, large adenoids/tonsils, or due to
airway obstruction from cricoid pressure (if used).
Functional problems may arise in the upper or lower airways. Upper
airway obstruction may be due to inadequate depth of anaesthesia and
laryngospasm; lower airway problems include inflation of the stomach
(very common in infants), bronchospasm or chest wall rigidity (rare).
====Management of difficult mask ventilation:====
:• Adjust the head position – does the child need a head roll (or
should the head roll be removed)
:• Use simple airway opening manoeuvres (chin lift, jaw thrust)
:• Apply positive end expiratory pressure (PEEP)
:• Adjust cricoid pressure if it has been used
:• Insert an oropharyngeal airway (if the patient is deep enough)
:• Increase depth of anaesthesia
:• Ventilate using a two-person technique (one holding the mask with two hands, the other ventilating by squeezing the bag)
== REFERENCES ==
== REFERENCES ==
Retrieved from "https://pedsanesthesia.net/wiki/index.php/Special:MobileDiff/2997"

Navigation menu