MANAGEMENT STRATEGIES FOR THE DIFFICULT PEDIATRIC AIRWAY

A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study

INTRODUCTION

Difficult airway management in children is challenging. One alternative device to the gold standard of direct laryngoscopy is the STORZ Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany), a rigid fiberoptic stylette-like scope with a curved tip. Although results in adults have been encouraging, reports regarding its use in children have been conflicting. We compared the effectiveness of a standard laryngoscope to the Bonfils fiberscope in a simulated difficult infant airway.

METHODS

Ten pediatric anesthesiologists were recruited for this study and asked to perform three sets of tasks. For the first task, each participant intubated an unaltered manikin (SimBaby (TM), Laerdal, Puchheim, Germany) five times using a styletted 3.5 endotracheal tube (ETT) and a Miller 1 blade (group DL-Normal). For the second task, a difficult airway configuration simulating a Cormack-Lehane grade 3B view was created by fixing a Miller-1 blade into position in the manikin using a laboratory stand. Each participant then intubated the manikin five times with a styletted 3.5 ETT using conventional technique but without touching the laryngoscope (group DL-Difficult). In the third task, the manikin was kept in the same difficult airway configuration, and each participant intubated the manikin five times using a 3.5-mm ETT mounted on the Bonfils fiberscope as an adjunct to direct laryngoscopy with the Miller-1 blade (group BF-Difficult). Primary outcomes were time to intubate and success rate.

RESULTS

A total of 150 intubations were performed. Correct ETT placement was achieved in 100% of attempts in group DL-Normal, 90% of attempts in group DL-Difficult and 98% of attempts in BF-Difficult. Time to intubate averaged 14 s (interquartile range 12-16) in group DL-Normal; 12 s (10-15) in group DL-Difficult; and 11 s (10-18) in group BF-Difficult. The percentage of glottic opening seen (POGO score) was 70% (70-80) in group DL-Normal; 0% (0-0) in group DL-Difficult; and 100% (100-100) in group BF-Difficult.

DISCUSSION

The Bonfils fiberscope-assisted laryngoscopy was easier to use and provided a better view of the larynx than simple direct laryngoscopy in the simulated difficult pediatric airway, but intubation success rate and time to intubate were not improved. Further studies of the Bonfils fibrescope as a pediatric airway adjunct are needed.

Proposal for the management of the unexpected difficult pediatric airway

The incidence of unanticipated difficult or failed airway in otherwise healthy children is rare, and routine airway management in pediatric patients is easy in experienced hands. However, difficulties with airway management in healthy children are not infrequent in nonpediatric anesthetists and are a main reason for pediatric anesthesia-related morbidity and mortality. Clear concepts and strategies are, therefore, required to maintain oxygenation and ventilation in children. Several complicated algorithms for the management of the unanticipated difficult adult and pediatric airway have been proposed, but a simple structured algorithm for the pediatric patient with unanticipated difficult airway is missing. This paper proposes a simple step-wise algorithm for the unexpected difficult pediatric airway based on an adult Difficult Airway Society (DAS) protocol, discusses the role of recently introduced airway devices, and suggests a content of a pediatric airway trolley. It is intended as an easy to memorize and a practical guide for the anesthetist only occasionally involved in pediatric anesthesia care as well as a call to stimulate discussion about the management of the unanticipated difficult pediatric airway.

A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway--a randomized clinical trial

INTRODUCTION

Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15 degrees . The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80 degrees . We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway.

METHODS

In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack-Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded.

RESULTS

TTBV in DL was 5.5 (4-8) s and 7 (4.2-9) s in VL. TTI in DL was 21 (17-29) s and in VL 27 (22-37) s (P = 0.006). The view as assessed by POGO score was 97.5% (60-100%) in DL and 100% (100-100%) in the VL (P = 0.003). Data are presented as median and interquartile range and analyzed using t-test.

DISCUSSION

This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways: A survey

PURPOSE

To survey Canadian pediatric anesthesiologists to assess practice patterns in managing pediatric patients with difficult airways.

METHODS

Canadian pediatric anesthesiologists were invited to complete a web survey. Respondents selected their preferred anesthetic and airway management techniques in six clinical scenarios. The clinical scenarios involved airway management for cases where the difficulty was in visualizing the airway, sharing the airway and accessing a compromised airway.

RESULTS

General inhalational anesthesia with spontaneous respiration was the preferred technique for managing difficult intubation especially in infants (90%) and younger children (97%), however, iv anesthesia was chosen for the management of the shared airway in the older child (51%) where there was little concern regarding difficulty of intubation. Most respondents would initially attempt direct laryngoscopy for the two scenarios of anticipated difficult airway (73% and 98%). The laryngeal mask airway is commonly used to guide fibreoptic endoscopy. The potential for complete airway obstruction would encourage respondents to employ a rigid bronchoscope as an alternate technique (17% and 44%).

CONCLUSION

Inhalational anesthesia remains the preferred technique for management of the difficult pediatric airway amongst Canadian pediatric anesthesiologists. Intravenous techniques are relatively more commonly chosen in cases where there is a shared airway but little concern regarding difficulty of intubation. In cases of anticipated difficult intubation, direct laryngoscopy remains the technique of choice and fibreoptic laryngoscopy makes a good alternate technique. The use of the laryngeal mask airway was preferred to facilitate fibreoptic intubation.