Recognizing and Managing the Difficult Pediatric Airway: Difference between revisions

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!

* If possible, always maintain spontaneous ventilation.

Many induction techniques can be used to maintain spontaneous ventilation, both inhalational or IV.  

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.     

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

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.

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.