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Recognizing and Managing the Difficult Pediatric Airway: Difference between revisions
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Recognizing and Managing the Difficult Pediatric Airway (view source)
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Difficult pediatric airway consists of difficulty in face-mask ventilation, direct or indirect laryngoscopy, tracheal intubation, supraglottic airway device placement or front-of-neck airway. In summary, it is the impossibility to ensure adequate oxygenation after general anesthesia induction. As so, that is the priority while facing a difficult airway: to guarantee oxygenation! | |||
Remember of the following particularities of pediatric patients before airway management, specially in the smaller ones (age < 2 yo): | |||
* They have big heads: occiput is large relative to the rest of the body, leading to airway obstruction due to cervical spine flexion. Place shoulder roll to optimize airway alignment; | |||
* They have large, omega-shaped epiglottis. Sometimes, it is necessary to pinch epiglottis during laryngoscopy to visualize vocal cords; | |||
* They have high oxygen consumption and low functional residual capacity, causing faster desaturation during apnea periods; | |||
* They are susceptible to gastric distension during face-mask ventilation. As the stomach increases its volume, the diaphragm is cephalically displaced, hampering face-mask ventilation. As harder it is tried to ventilate in this situation, more air is forced into the stomach and it becomes even harder to ventilate, creating a vicious cycle. When a previously easy face-mask ventilation becomes hard after a long period of ventilation, ALWAYS remember of gastric distention. Place a orogastric tube to empty the stomach! | |||
The main risk factors for difficult airway in pediatric patients are the following: genetic syndromes (specially the ones which present craniofacial anomalies); Micrognathia; Weight < 10 kg (small children); > 3 direct laryngoscopy attempts; > 2 tracheal intubation attempts. As you may see from this list, a very important principle in pediatric airway management is to limit intubation attempts, as further manipulation of children's airway increase the risk of complications. | |||
Some principles must be followed in difficult pediatric airway management: | |||
* Call for help; | |||
* Have a supraglottic airway device available to rescue airway in case of difficult face-mask ventilation; | |||
* Provide passive oxygenation until airway is guaranteed. It is possible to use high-flow devices or low-flow devices, such as nasal or pharyngeal cannulas. In any case, always be aware of gastric distension. If using a low-flow device, limit the flow to 2 L/min to avoid this complication; | |||
* Have advanced airway devices in the operating room, such as video laryngoscope and/or flexible fiberoptic bronchoscope; | |||
* If possible, always maintain spontaneous ventilation. | |||
=== General anesthesia induction under spontaneous ventilation === | |||
Many induction techniques can be used to maintain spontaneous ventilation, both inhalational or IV. | |||
If using inhaled agents alone, such as sevoflurane, remember that MAC BAR is around 1.5 - 2 MAC and titrate the dose to adequate anesthetic plan for airway manipulation. | |||
In the impossibility of inhalational induction, it is possible to use IV agents alone. Ketamine is a good choice, as it has analgesic properties and produces less respiratory depression than other hypnotic drugs. It is also described the use of propofol or low doses of midazolam + fentanyl for this purpose. If using ketamine or propofol, titrate incremental doses of 0,25-0,5 mg/kg until adequate anesthetic plan. A side effect of ketamine is sialorrhea, that may difficult airway visualization. In this case, the use of a antisialagogue agent, such as atropine or glycopyrrolate, may be necessary. | |||
Another possibility is the combination of both IV and inhaled agents for anesthesia induction, such as sevoflurane and ketamine. In this case, a lesser dose from the two anesthetics is used, reducing adverse effects and providing a better anesthetic plan. | |||
A way to test if the patient is in adequate anesthetic plan for airway manipulation is to perform a 5-second jaw-thrust. In the absence of movement, tachycardia and tachypnea, the patients is considered to be in a small risk of airway reaction during manipulation. | |||
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