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''Originally from Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia''
''Originally from Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia''
Michelle C White* and Jonathan M Linton
:<i>*Correspondence email: mcwdoc@doctors.org.uk</i>
Dr Michelle White, Consultant Anaesthetist, Mercy Ships, Guinea
Dr Jonathan Linton, Specialist Trainee Anaesthesia, University Hospital, Southampton, UK
{| class="wikitable"
|+Summary
!Unexpected difficult airways in paediatric practice are rare. Many problems can be prevented by routine preoperative airway assessment, pre- xygenation, and preparation of equipment. A simple step-wise approach to management improves outcome. Anaesthetists have a responsibility to be familiar with airway algorithms and make pragmatic modifications to account for available resources.
|}
== INTRODUCTION ==
Airway management in children is generally
straightforward in experienced hands. Problems are
more common for the non-paediatric anaesthetist,
and are a major cause of anaesthesia-related morbidity
and mortality. Genuine ‘difficult airways’ are rare in
children compared to adults and many are predictable.
However, differences in adult and paediatric physiology
mean irreversible hypoxic damage occurs more quickly
in children if there is an airway problem. Simple stepwise
strategies are essential. Many guidelines exist for
the management of difficult airways in adults, but there
are few specifically designed for use in children.
The aim of this article is to outline the basic principles
of paediatric airway assessment and to discuss the
management of unexpected and expected difficult
paediatric airways.
Evidence to support best practice is difficult to obtain
for unpredictable events such as management of the
paediatric difficult airway, and there is a lack of high
quality data. Many new devices and techniques are
available, but most are evaluated in healthy children
or simulated ‘difficult’ situations. Due to this lack of
evidence, guidelines are often based on a consensus of
expert opinion, which may have a bias against newer
devices and techniques, or indeed bias towards the
latest technique that has gained popularity. This review
takes a pragmatic and cautious approach in applying
existing guidelines to settings where experts and a range
of technology are not always available.
== BACKGROUND ==
Management of the difficult airway can be divided into
three critical areas:
:1. Difficult mask ventilation
:2. Difficult tracheal intubation
:3. Can’t intubate and can’t ventilate (CICV).
The incidence of difficult airways in children
is unknown. The incidence of impossible mask
ventilation is reported as 0.15%, and is more frequently
encountered by inexperienced paediatric anaesthetists.
Difficult intubation ranges from 0.05%, rising to
0.57% in children less than one year of age.<ref>Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult
pediatric airway. Pediatr Anesth 2010; 20: 454-64. http://onlinelibrary.wiley.com/
doi/10.1111/j.1460-9592.2010.03284.x/pdf</ref><sup></sup> Difficult intubation is more common in children with cleft lip
and palate (4.7%) and cardiac abnormalities (1.25%),
most likely related to associated syndromes or limited
cardiac reserve.
An audit of difficult airway management in the UK
in 2001 (the 4th National Audit Project, NAP 4),
prospectively measured major airway complications
in almost 115,000 patients undergoing anaesthesia.<ref>The 4th National Audit Project of the Royal College of Anaesthetists and the
Difficult Airway Society: Major Complications of Airway Management in the
United Kingdom. March 2011. http://www.rcoa.ac.uk/nap4/</ref><sup></sup>
Children comprised a small proportion of the total
population, and complications were rare (only 7-8%
of total complications).
Common contributing factors to bad outcomes were:
:• Poor airway assessment
:• Poor planning
:• ‘Failure to plan for failure’
:• Repeated attempts at intubations
:• Lack of monitoring (oxygen saturation and capnography)
:• Slow response to hypoxia resulting in bradycardia leading to cardiac arrest
:• Failure to use devices such as the laryngeal mask airway (LMA) when faced with a difficult intubation.
One of the key findings in NAP4 was the ‘failure to
plan for failure’. Airway management plans should
always include a back-up plan to use if the first plan
fails. Whenever unexpected difficulties occur, seek
experienced help immediately. Another key finding
of NAP4 was that repeated attempts at intubation can
cause severe airway oedema in children and worsen the
situation, hence their recommendation, ‘a change of
approach is required, not repeated use of a technique
that has already failed’.
Many countries have adult guidelines for management
each of difficult airways, but few have child specific
guidelines. The Association of Paediatric Anaesthetists
of Great Britain and Ireland (APA) published paediatric
guidelines in 2012, which are shown in Figures 1-3
and form the basis for management of the unexpected
difficult airway discussed here.<ref>The Association of Paediatric Anaesthetists (APA) Guidelines for difficult airway
management in children. 2012. http://www.apagbi.org.uk/publications/apaguidelines</ref><sup></sup>
== REFERENCES ==
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