Recognizing and Managing the Difficult Pediatric Airway

Introduction

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. The harder it is tried to ventilate in this situation, more air is forced into the stomach and it becomes even harder to ventilate afterall, creating a vicious cycle. When a previously easy face-mask ventilation becomes harder after a long period of ventilation, ALWAYS remember of gastric distention. Place an 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;
• Communicate surgery team and prepare for the possibility of a surgical airway;
• 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 an 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.

Difficult bag-mask ventilation

In the scenario of difficult ventilation, the following steps can be considered:

• place an oropharyngeal or nasopharyngeal device;
• correct positioning and technique: place shoulder roll, if indicated; use two hands, making chin lift and jaw thrust maneuvers; consider lateral decubitus to help opening upper airway;
• remember of laryngospasm. If present, use CPAP and deepen anesthetic plane. Consider muscular relaxant if refractory laryngospasm;
• remember of gastric distension. If present, empty stomach with an orogastric tube;

If none of the measures above work, place a supraglottic airway device (SAD). If adequate ventilation is obtained and the surgery can be safely conducted with the SAD, proceed. However if tracheal intubation is needed, use the SAD as a conduit to fiberoptic intubation. Nevertheless, if SAD fails to grant adequate ventilation, proceed to CICO scenario (cannot intubate, cannot oxygenate) or awake the patient if SpO2 permits (slow decline with stable hemodynamics). In CICO scenario, front-of-neck access must be made preferably by the surgery or ENT team. In the absence of them, anesthesiologist must perform a cricothyroidotomy by his/her preferable technique.

Easy bag-mask ventilation, difficult direct laryngoscopy

In this scenario, always remember to limit the attempts of laryngoscopy and intubation! Transition to indirect technique of laryngoscopy as soon as possible and use auxiliary devices as needed (e.g. bougie). If advanced techniques also fail, place a SAD and follow the steps described before.

Example of pediatric difficult airway algorithms

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Relevant Article Depot:

BJA: Difficult airway management: children are different from adults, and neonates are different from children!

Pediatric Anesthesia: Special Issue:Pediatric Airway Special Issue

NEJM: Management of the Difficult Airway

The Congenital Difficult Airway in Pediatrics

Decision Making in the Difficult Airway Algorithm

Error traps in pediatric difficult airway management

OA-SPA Virtual Grand Rounds / Management of the Difficult Pediatric Airway

10 Rules for Approaching Difficult Intubation: Always Prepare for Failure

Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching

https://pubmed.ncbi.nlm.nih.gov/33308472/

Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway

Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry

Difficult Airway Management in Neonates: Fiberoptic Intubation via Laryngeal Mask Airway

Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database

Prediction of Difficult Laryngoscopy Using Ultrasound: A Systematic Review and Meta-Analysis

Preventing difficult facemask ventilation in children: all is well that starts well

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

Airway triage: a novel application-based method for airway assessment and risk stratification

Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study