Pediatric Airway Management

James Y. Choi, M.D. Associate Professor Pediatric Anesthesiology University of Iowa Heath Care Iowa City, Iowa

Objectives
Unique aspects of pediatric airway management
Airway Anatomy Respiratory Physiology

Routine pediatric airway management Difficult pediatric airway management

Pediatric Airway Anatomy

Smaller airway diameter

R = 8L r4

R= airflow resistance L= length

r = radius = gas viscosity

Pediatric Airway Anatomy

Pediatric Airway Anatomy

Pediatric Airway Anatomy

Pediatric Airway Anatomy

Larynx position
At birth: C1-C4 Adult position: C4-C7

VC with anterior angulation Prominent arytenoid cartilages Large occiput

Pediatric Airway Anatomy

Pediatric Respiratory Physiology

Metabolism
Higher BMR in infants Higher O2 consumption/CO2 production Higher ventilatory requirement

Pediatric Respiratory Physiology

Functional residual capacity (FRC)
Balance between outward recoil of rib cage and inward recoil of the lungs Young infants rib cage is highly compliant, inward recoil is often greater than outward recoil
Poorly supported by surrounding structures Poorly maintained negative intrathoracic pressure Requires less pressure to ventilate

Infants FRC per weight basis is smaller than that of the adults

Pediatric Respiratory Physiology

Pediatric Respiratory Physiology

Resistance to volatile agents
Upper airway muscles very sensitive to the effects of anesthetic agents Infant upper airway muscles more sensitive than that of adult Frequent upper airway obstruction during inhalation induction

Difficulties Unique To Pediatric Airway Management

Anatomical
Smaller size VC location & angulation Shape of the epiglottis Larger occiput

Physiological
Frequent upper airway obstruction under anesthesia Higher metabolism, smaller FRC, faster desaturation

Pre-operative assessment Awake fiberoptic intubation usually not an option Regional Anesthesia usually not an option

Routine Pediatric Airway

Pre-operative evaluation
History Airway examination difficulties
Uncooperative Frontal examination may not reveal Micrognathia

Routine Pediatric Airway

Equipments
Masks Airways Laryngoscope blades Correct size, one size up, one size down Stylet Circuit & bag LMA Emergency drugs in small syringes with needle

Routine Pediatric Airway

Positioning
Bed height Large occiput
Rolled towel to stabilize head Rolled towel to elevate shoulder

Routine Pediatric Airway

Routine Pediatric Airway

Induction
IV Inhalation IM

Difficult Airway Management

Incidence of unanticipated difficult pediatric airway is low Most of the airway difficulties associated with congenital syndromes

Difficult Airway Syndromes

Pierre-Robin Treacher-Collins Goldenhaars Mucopolysaccharidosis Downs Edwards Freeman-Sheldon Kenny-Caffey Schwartz-Jampel Cri du chat

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Anticipated Difficult Airway Management

Direct laryngoscopy Alternatives to endotracheal intubation Alternatives to direct laryngoscopy

Anticipated Difficult Airway Management

Alternatives to endotracheal intubation
Mask airway +/- oral airway LMA

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Anticipated Difficult Intubation

Mask airway +/- oral airway
For short surgeries Minimally invasive Does not protect against aspiration Hands not available

Anticipated Difficult Intubation

LMA advantages
Technically not difficult Frees up your hands Less invasive than intubation Controlled or spontaneous ventilation Can be used as the main airway device Can be used as a conduit to facilitate fiberoptic intubation

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Anticipated Difficult Intubation

LMA disadvantages
Does not protect against aspiration Smaller LMAs can be dislodged easily Can cause soft tissue trauma

Anticipated Difficult Intubation

Weight (Kg) <5 5-10 10-20 20-30 > 30 LMA Size 1 1.5 2 2.5 3 Largest ETT (mm ID) 3.5 4 4.5 5 6

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Anticipated Difficult Intubation

LMA Preparation
Lubrication Size No wrinkles Partially inflated

Anticipated Difficult Intubation

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Anticipated Difficult Intubation

Alternative LMA Insertion methods
Start with the cuff turned 180 degrees Corkscrew Start with the LMA on either side of the mouth Apply steady downward pressure

Anticipated Difficult Intubation

LMA assisted intubation
Blind Fastrach Fiberoptic

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Anticipated Difficult Intubation

LMA assisted fiberoptic intubation
If the LMA is seated properly, usually very easy Equipment
Long straight hemostat Wire / Tube exchanger Swivel adaptor

LMA Assisted Fiberoptic Intubation

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LMA Assisted Fiberoptic Intubation

LMA Assisted Fiberoptic Intubation

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LMA Assisted Fiberoptic Intubation

LMA Assisted Fiberoptic Intubation

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LMA Assisted Fiberoptic Intubation

Anticipated Difficult Airway Management

Alternatives to direct laryngoscopy
Lighted stylet
Light wand Shikani stylet

Bullard Laryngoscopes Fiberoptic intubation Surgical airway

Retrograde wire Cricothyroidotomy Tracheostomy

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Anticipated Difficult Intubation

Difficulties in Pediatric asleep fiberoptic intubation
Small size Unable to use intubating airway If spontaneous respiration, often has upper airway obstruction Shorter time before desaturation Cephalad VC Anterior angulation of the VC Prominent arytenoids, long floppy epiglottis

Anticipated Difficult Intubation

Asleep fiberoptic intubation
Antisialogogue LMA assisted if possible Assistant to pull the tongue out of the way Spontaneous respiration Adequate anesthetic Keep it straight and centered Practice on routine pediatric airways If difficulty advancing the ETT, turn 90 counterclockwise

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Unexpected Difficult Airway Management

Do not continue to do the same thing and expect a different result

Unanticipated Difficult Airway Management

Difficult mask airway
Oral airway 2 person mask airway Deepen the anesthetic LMA Attempt intubation Awaken the patient Surgical airway

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Unanticipated Difficult Airway Management

Unable to intubate
Reestablish mask ventilation Ensure optimal positioning Consider using a different blade LMA Alternative techniques Awaken the patient Surgical Airway

Unanticipated Difficult Airway Management

Alternative techniques
Call for help Have all the airway equipment available Antisialogogue Adequate anesthetic Spontaneous respiration

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ASA Difficult Airway Algorithm

Unexpected Difficult Intubation

Surgical airway
Retrograde wire Cricothyroidotomy Tracheostomy

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Surgical Airway
Retrograde wire
Commercial kits available Alternative equipment
18G IV catheter Non-flexible tip epidural catheter

May be technically difficult

Cook Retrograde Wire Kit

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Retrograde Wire

Retrograde Wire

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Surgical airway
Cricothyroidotomy
Commercial kits available Alternative equipment
18G IV catheter 3 cc luerlock syringe Tube connector from 7.0 mm OETT

Cricothyroidotomy

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Summary
Unique aspects of pediatric airway management Systematic approach to difficult pediatric airway management Small problems add up to a big problem, pay attention to small details, details, details Always have a backup plan and a backup plan to the backup planbefore getting started

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