The laryngeal mask airway in the difficult paediatric airway: an assessment of positioning and use in fibreoptic intubation

Comparison of laryngeal mask airway (LMA) insertion with and without muscle relaxant in pediatric anesthesia; a randomized clinical trial

Introduction

This study aimed to evaluate the effectiveness of using muscle relaxant on the ease of laryngeal mask airway (LMA) insertion and possibility of its related complications.

Methods

This double-blind, randomized clinical trial was performed on 60 children aged 1–4 years with ASA (American Society of Anesthesiology) I or II with upper limb injuries who were candidates for surgery. The patients were randomly allocated to the two groups receiving atracurium group as muscle relaxant (MR) or saline group (S).

Results

Regarding ease of placement, the LMA was inserted in 66.7% and 63.3% of patients straightforwardly in the MR and S groups, respectively. While it was performed with one maneuver in 23.3% and 26.7% of cases in the MR and S groups, respectively (p = 0.955). Moreover, LMA dislodgment in the two groups was 36.7% in the MR group and 20.0% in the S group without a meaningful difference (P = 0.152). The only complication observed in the two groups was laryngospasm, which occurred in 0.10% and 13.3% in the MR and S groups, respectively (p = 0.688).

Conclusion

In some pediatric anesthesia, the use of atracurium, as a muscle relaxant had no significant effect on capability of LMA insertion, maintaining airway patency, LMA seal pressure and oxygenation variations. Moreover, it did not have a preventive effect on the occurrence of complications such as laryngospasm.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Airway management and perioperative adverse events in children with mucopolysaccharidoses and mucolipidoses: A retrospective cohort study

BACKGROUND

Children suffering from mucopolysaccharidoses (subtypes I, II, III, IV, VI, and VII) or mucolipidoses often require anesthesia, but are at high risk for perioperative adverse events. However, the impact of the disease subtype and the standard of care for airway management are still unclear.

AIMS

This study aimed to assess independent risk factors for perioperative adverse events in individuals with mucopolysaccharidoses/mucolipidoses and to analyze the interaction with the primary airway technique implemented.

METHODS

This retrospective study included individuals with mucopolysaccharidoses/mucolipidoses who underwent anesthesia at two high-volume centers from 2002 to 2016. The data were analyzed in a multivariate hierarchical model, accounting for repeated anesthesia procedures within the same patient and for multiple events within a single anesthesia.

RESULTS

Of 141 identified inpatients, 67 (63 mucopolysaccharidoses and 4 mucolipidoses) underwent 269 anesthesia procedures (study cases) for 353 surgical or diagnostic interventions. At least one perioperative adverse event occurred in 25.6% of the cases. The risk for perioperative adverse events was higher in mucopolysaccharidoses type I (OR 8.0 [1.5-42.7]; P = .014) or type II (OR 8.8 [1.3-58.6]; P = .025) than in type III. Fiberoptic intubation through a supraglottic airway was associated with the lowest risk for perioperative adverse events and lowest conversion rate. Direct laryngoscopy was associated with a significantly higher risk for airway management problems than indirect techniques (estimated event rates 47.8% vs 10.1%, OR 24.05 [5.20-111.24]; P < .001). The risk for respiratory adverse events was significantly higher for supraglottic airway (22.6%; OR 31.53 [2.79-355.88]; P = .001) and direct laryngoscopy (14.8%; OR 14.70 [1.32-163.44]; P = .029) than for fiberoptic intubation through a supraglottic airway (2.1%).

CONCLUSIONS

The disease subtype and primary airway technique were the most important independent risk factors for perioperative adverse events. Our findings indicate that in MPS/ML children with predicted difficult airway indirect techniques should be favored for the first tracheal intubation attempt.

The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel

Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient’s death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.

Comparison of weight-based and pinna size-based selection of ProSeal laryngeal mask airway in paediatric population - A prospective exploratory trial

Background and Aims

Weight-based selection of ProSeal laryngeal mask airway (PLMA) size may be unreliable in some situations. The aim of this study was to compare the ventilation parameters using PLMA during controlled ventilation between weight-based size selection and pinna size-based selection in children.

Methods

A total of 204 patients were randomised to receive either pinna size-based (Group P) or weight-based (Group W) size selection of PLMA. We tested the hypothesis that pinna size-based selection of PLMA was better than weight-based selection of PLMA in paediatric patients during controlled ventilation under general anaesthesia in terms of oropharyngeal sealing pressure (the primary end-point) and Brimacombe score. Cuff pressure was maintained at 60 cm of H₂O during the study. Secondary outcomes included the number of attempts for successful placement of PLMA, peak airway pressure, gastric tube placement, traumatic insertion, and complications were also compared. Parametric variables were analysed using unpaired t-test and categorical variables were analysed using Mann-Whitney and Chi-square test.

Results

In all, 200 patients were analysed. The mean oropharyngeal sealing pressure in Group P was 25.4 ± 3.5 cmH₂O and 24.9 ± 3.8 cmH₂O in Group W, (P = 0.34). There was no significant difference between the two groups in any of the secondary outcomes. There were no traumatic insertion or complications reported in both the groups.

Conclusion

Pinna-based size selection method can be used in PLMA placement in the paediatric population for positive pressure ventilation and it serves as an alternative method to weight-based selection.

Anesthesiological risks in mucopolysaccharidoses

Background

Patients suffering from mucopolysaccharidosis are among the most complex from the anesthesiological point of view, especially regarding the management of the airway. The evidence base for anesthesia management is often limited to case reports and small case series.

Aims

To identify useful information about experience with each subtype of mucopolysaccharidosis reported in the literature and propose a guide on the best options for airway management to the anesthesiologists who take care of these patients.

Methods

A query of the PubMed database specific for “anesthesia” and “mucopolysaccharidosis” and a further query specific for “mucopolysaccharidosis and difficult airway management” was conducted. We looked for those items that offered practical guidance to anesthesiological management. We did not exclude case reports, especially those that reported a specific technique, because of their practical suggestions.

Results

We identified 15 reviews, 17 retrospective case series, 5 prospective studies, and 28 case reports that focused on airway managements in anesthesia or had practical suggestions for preoperative evaluation and risk assessment. An accurate preoperative evaluation and the need for an experienced team are emphasized in all the reviewed articles and for each type of mucopolysaccharidosis. Many suggestions on how to plan the perioperative period have been highlighted. Insertion of a laryngeal mask airway generally improves ventilation and facilitates intubation with a fiberoptic bronchoscope. Furthermore, the videolaryngoscope is very useful in making intubation easier and facilitating bronchoscope passage.

Conclusions

Patients with mucopolysaccharidosis are at high risk for anesthesia-related complications and require a high level of attention. However, a multidisciplinary approach, combined with expertise in the use of new techniques and new devices for airway management, makes anesthesiological management safer. Further research with prospective studies would be useful.

Electronic supplementary material

The online version of this article (10.1186/s13052-018-0554-1) contains supplementary material, which is available to authorized users.

Anaesthetic Implications of the Changing Management of Patients with Mucopolysaccharidosis

The mucopolysaccharidoses are a group of inherited metabolic disorders that are renowned for presenting clinical problems, particularly related to cardiac, airway, and skeletal abnormalities, in children during anaesthesia. The changing clinical management of the mucopolysaccharidoses can be described in three phases. An initial phase of accumulation and dissemination of knowledge about the management of this rare disease with a growing recognition that untreated Hurler syndrome and more severe forms of other phenotypes such as Hunter syndrome and Maroteaux–Lamy syndrome were associated with severe complications under anaesthesia. This was followed by a second phase reflecting the beneficial results of new treatments such as haemopoietic stem cell transplantation and enzyme replacement therapy. Early and successful transplantation has dramatically improved long-term outcome and reduced anaesthetic complications in children with Hurler syndrome. Enzyme replacement therapy is available for many forms of mucopolysaccharidosis. If commenced at an early age improvement in many organ systems may be observed with an improved quality of life. However, these current treatment regimens do not appear to improve neurocognitive dysfunction, or cardiac valvular or skeletal abnormalities. We are now entering a third phase where the partial benefits of these treatment regimens are resulting in an increasing number of older patients with partially corrected abnormalities, including difficult airways, presenting for ongoing treatment to a new and potentially unsuspecting group of clinicians. Major airway abnormalities may be encountered and current adult guidelines may need to be adapted. A multidisciplinary team approach involving paediatric and adult anaesthetists is recommended to optimise future management.

Small is the new big: An overview of newer supraglottic airways for children

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Management of Difficult Airway in a Failed Intubation with Videolaryngoscopy in an Infant Patient

The videolaryngoscope is a useful alternative airway device for anaesthesia management of difficult airways. However videolaryngoscope intubation may fail due to lack of experience, incorrect application, inappropriate stylet, prior traumatic attempts, restricted cervical movement and limited oropharyngeal airspace. Using a stylet and correctly shaped endotracheal tube is important to facilitate tracheal intubation with the videolaryngoscope, especially in paediatric patients. However, anatomical difficulty in the placement of the laryngoscope blade, association with facial deformities such as micrognathia, having a short neck, cleft palate and being younger than 1 year increase the likelihood of a difficult airway. In this report, we present our approach to difficult airway management in a failed intubation with a videolaryngoscope in an infant undergoing cleft palate surgery.

Management of difficult airway patients and the use of a difficult airway registry at a tertiary care pediatric hospital

BACKGROUND

Appropriate recognition and management of the pediatric difficult airway is essential. Two patient deaths in a 2-year period involving children with a known difficult airway led to the formation of the institution's multidisciplinary Difficult Airway Committee.

METHODS

Patients with a suspected difficult airway or a known difficult airway are entered into a registry of difficult airway patients. A note describing the airway and any experiences at airway manipulation is entered as part of a difficult airway note in the patient's electronic medical record as soon as the patient is recognized as having a difficult airway. A call system has been developed to mobilize expert emergency airway assistance for these patients. Multiple additional methods are employed to ensure that all hospital personnel are aware that these patients are difficult to intubate.

RESULTS

Since inception almost 6 years ago, 164 patients (mean age 9.2 years) have been enrolled in the difficult airway registry. Eighty-seven patients (53%) had one of 28 identified syndromes or diagnoses. The most common reasons for airway obstruction were mandibular hypoplasia/micrognathia, decreased neck extension, and limited temporomandibular joint mobility. One hundred sixty-one patients (98%) in the registry were predicted by history or physical to have a difficult airway. The mortality of registry patients was 9.8% (n = 16) and was most commonly due to co-existing diseases. During the time period reviewed, there was one in-hospital death of a known difficult airway patient, in which expert airway assistance was not obtained in a timely fashion.

CONCLUSION

The institution's difficult airway registry identifies patients with a suspected or known difficult airway. The presence of a difficult airway in children can usually be predicted based on history and physical examination by anesthesiologists and otolaryngologists. Providers without advanced airway skills, however, may not appreciate that an airway is difficult to intubate until multiple attempts have failed. Both redundant notification methods and a call system optimize medical care of these fragile patients.

Pediatric airway management

Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.

The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient

Background

Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.

Methods

Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.

Conclusions

The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.

Difficult pediatric airway management using the intubating laryngeal airway

OBJECTIVE

To evaluate the intubating laryngeal airway (ILA) in providing safe endotracheal intubation in pediatric patients with difficult airway; to describe a method for using flexible fiberoptic bronchoscopy with the ILA for evaluating the pediatric airway.

METHODS

Case series with chart review of the medical records of patients who had the ILA and fiberoptic intubation used to secure the airway at a tertiary pediatric hospital from January 2009 to January 2011. We documented the circumstances necessitating airway management, ILA success, airway evaluation findings, and medical conditions contributing to difficult airway.

RESULTS

Fifty patients met criteria for review. The median age was 59.8 months (0.3-244.1), and the median weight was 19.0 kg (2.6-86). Four cases (8%) were unanticipated difficult airways and 46 (92%) were anticipated difficult airways. Nine (18%) of the 50 procedures were performed emergently. Comorbid conditions included craniofacial syndromes (n=36), cervical spine instability/immobility (n=9), and airway hemorrhage (n=3). 48 (96%) patients were fiberoptically intubated on first attempt through the ILA. In 2 patients, fiberoptic intubation required a second attempt. The overall success rate using the ILA and fiberoptic intubation to secure the airway was 100%.

CONCLUSION

ILA and fiberoptic-guided tracheal intubation is a safe and effective method for securing the airway in pediatric patients with difficult airway and can be a useful alternative to direct laryngoscopy when laryngeal exposure is suboptimal.

A child with a difficult airway: what do I do next?

PURPOSE OF REVIEW

Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway.

RECENT FINDINGS

Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential.

SUMMARY

The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.

Mucopolysaccharidosis type I (Hurler syndrome) and anesthesia: the impact of bone marrow transplantation, enzyme replacement therapy, and fiberoptic intubation on airway management

AIM

To assess the effect of bone marrow transplantation (BMT), enzyme replacement therapy (ERT), and a fiberoptic endotracheal intubation technique in patients with mucopolysaccharidosis type I (MPS I, Hurler syndrome).

BACKGROUND

The mucopolysaccharidoses are inherited metabolic conditions with a well-documented association with difficult airway management. We present the largest series to date of patients with Hurler syndrome (MPS I) and look at the impact of new treatments, such as BMT and ERT, on anesthesia and airway management.

METHODS/MATERIALS

We carried out a retrospective chart review of patients with MPSI undergoing anesthesia over 9 years at the Royal Manchester Children's Hospital. Data were collected on incidence of difficult and failed intubation and airway difficulties under anesthesia.

RESULTS

There were 39 patients identified, of which 20 had the attenuated form of MPS I and received ERT, 18 were treated by BMT and one patient received neither treatment. These patients had a total of 114 general anesthetics for 141 procedures. The incidence of airway complications overall is lower than previously reported at 31%. Patients with the attenuated form of the disease on ERT still have a high incidence of airway problems at 57% and a failed intubation rate of 3%. BMT patients on the other hand have a much lower incidence of airway complications at 14%, and there were no failed intubations in this group.

CONCLUSIONS

Managing the MPS1 patient continues to be a challenge but with treatment and newer forms of airway management it is improving.

Paediatric airway management in mucopolysaccharidosis 1: a retrospective case review

CONTEXT

Airway management in children suffering from mucopolysaccharidosis 1 (Hurler syndrome) remains challenging despite advances in both treatment and airway management techniques.

OBJECTIVES

Forty-one anaesthetic charts following ten children over a 6-year period (2004-2010) were reviewed with emphasis on airway problems.

RESULTS

All children had early stem cell transplantation at the age of 2 years or earlier. Mean (SD) age was 5 (4.3) years. Mask ventilation was difficult in five of 41 (12%) anaesthetics or in three of ten children. There were 29 intubations. Direct laryngoscopy was described as difficult (Cormack and Lehane ≥3) on 11 occasions in five of ten children. There were three of 26 (12%) failed intubations with direct laryngoscopy. These situations were resolved by a fibre-optic procedure, by laryngeal mask airway (LMA) insertion or by use of a videolaryngoscope. A laryngeal mask airway was used 11 times to avoid invasive airway management and once when direct laryngoscopy was impossible.

CONCLUSION

The airway management of children with mucopolysaccharidosis 1 remains critical, despite advances in both treatment and airway management techniques. Problems did not seem to increase as children grew older. We assume that technical improvements such as standardised use of the laryngeal mask airway or attached tube channel videolaryngoscopes as well as a stem cell transplantation treatment of the disease helped the management of older children with mucopolysaccharidosis 1.

Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review

PURPOSE

This article is a narrative review regarding the usage and effectiveness of introducers or catheters to facilitate tracheal intubation through a supraglottic airway (SGA) as an alternative intubation technique in normal and difficult airway management.

SOURCES

Relevant articles were obtained through Medline (1948-July 2011). The articles were subsequently cross-referenced for additional literature, and only articles published in English were included.

PRINCIPAL FINDINGS

In this review, we consider 32 reports using the LMA Classic™, LMA Unique™, LMA ProSeal™, LMA Supreme™, AuraOnce™, and i-gel™ as SGA conduits for intubation. In 13 articles, the use of an Aintree Intubation Catheter was described as an intubation introducer and resulted in high success rates in both elective and emergent situations. Eight studies used a guidewire exchange catheter technique. Although blind intubation using a guidewire resulted in a high failure rate, these studies found that using a bronchoscope improved successful intubation. Ten studies showed that insertion of a gum elastic bougie with a bronchoscope as an intubation introducer has high success rates compared with blind bougie insertion. One article described the use of a small endotracheal tube as an intermediary for tracheal intubation.

CONCLUSIONS

In failed intubation scenarios, supraglottic airways, such as the LMA Classic™ or LMA ProSeal™ can serve as a conduit for tracheal intubation. A number of techniques using introducers or catheters can facilitate the insertion of an adequately sized endotracheal tube, particularly guided by a bronchoscope. Usage of introducers or catheters through a supraglottic airway may be a useful alternative intubation technique in difficult airway management.

Mucopolysaccharidosis type II: European recommendations for the diagnosis and multidisciplinary management of a rare disease

Mucopolysaccharidosis type II (MPS II) is a rare, life-limiting, X-linked recessive disease characterised by deficiency of the lysosomal enzyme iduronate-2-sulfatase. Consequent accumulation of glycosaminoglycans leads to pathological changes in multiple body systems. Age at onset, signs and symptoms, and disease progression are heterogeneous, and patients may present with many different manifestations to a wide range of specialists. Expertise in diagnosing and managing MPS II varies widely between countries, and substantial delays between disease onset and diagnosis can occur. In recent years, disease-specific treatments such as enzyme replacement therapy and stem cell transplantation have helped to address the underlying enzyme deficiency in patients with MPS II. However, the multisystem nature of this disorder and the irreversibility of some manifestations mean that most patients require substantial medical support from many different specialists, even if they are receiving treatment. This article presents an overview of how to recognise, diagnose, and care for patients with MPS II. Particular focus is given to the multidisciplinary nature of patient management, which requires input from paediatricians, specialist nurses, otorhinolaryngologists, orthopaedic surgeons, ophthalmologists, cardiologists, pneumologists, anaesthesiologists, neurologists, physiotherapists, occupational therapists, speech therapists, psychologists, social workers, homecare companies and patient societies.

Take-home message

Expertise in recognising and treating patients with MPS II varies widely between countries. This article presents pan-European recommendations for the diagnosis and management of this life-limiting disease.

Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway

OBJECTIVES

To assess the efficacy of the ILA as a conduit for tracheal intubation in pediatric patients with a difficult airway.

AIM

The primary goals of this retrospective audit were to assess the clinical performance of the ILA in pediatric patients with a difficult airway, expand on our initial favorable experience with this device, and collect pilot data for future prospective and comparison studies.

METHODS

The charts of patients with a difficult airway in whom the ILA was used during a period of 1 year in a freestanding pediatric institution were reviewed following a practice change in the authors' institution favoring the ILA over the laryngeal mask airway as a conduit for tracheal intubation.

RESULTS

Thirty-four pediatric patients had an ILA placed during the course of their airway management. Eight of the 34 patients in this cohort required emergent airway management. The median age was 47.1 (0.3-202.2) months and the median weight was 16.3 (3.9-86.0) kilograms. Three of the cases were unanticipated difficult airways and the remaining were anticipated difficult airways as a result of craniofacial syndromes (n = 21), cervical spine instability or immobility (n = 7), or airway hemorrhage (n = 3). Thirty-three of the 34 patients (97%) were intubated on the first attempt through the ILA, with the aid of a fiberoptic bronchoscope (n = 25), a Shikani Optical Stylet (n = 7), or blindly (n = 2). In one patient, blind tracheal intubation required a second attempt for successful intubation, making the overall success rate 100%. Oxygen desaturation was noted in 6 of the 34 cases.

CONCLUSIONS

In a series of pediatric patients with difficult airways, the ILA was successfully used as a conduit for tracheal intubation in all patients. Visualization techniques may offer a greater degree of success in intubations through the ILA due to the potential for epiglottic down-folding in children.

The anatomic relationship between the internal jugular vein and the carotid artery in children after laryngeal mask insertion. An ultrasonographic study

BACKGROUND

Central venous cannulation, although challenging in children and prone to complications, is frequently required for total parenteral nutrition and infusion of drugs.

AIM

The aim of this study was to determine the anatomic relationship between the internal jugular vein (IJV) and carotid artery (CA) before, and after, insertion of laryngeal mask airway (LMA) in children using ultrasound.

METHODS

Patients aged 2-16 were recruited to this prospective study and divided into three groups of 20 patients each: group 1: LMA size 2, group 2: LMA size 2½, and group 3: LMA size 3. Prior to, and following, LMA insertion, the position and depth of the vessels, and time to locate them were recorded. All measurements were taken at the level of the cricoid cartilage in a neutral head position in the spontaneously breathing patient during expiration. The IJV position in relation to the CA was noticed as anterior (A), anterolateral (AL), lateral (L), or medial (M).

RESULTS

The position of the IJV was found to be in the anterolateral (AL) or anterior (A) position to the CA in the majority of cases. The anatomic relationship changed in 10/120 (8.3%) following insertion of the LMA. The mean depth was 0.80 (± 0.15) cm for the right IJV before LMA insertion and 0.84 (± 0.17) cm after insertion. Similar measurements were taken on the left side [0.81 (± 0.14) cm and 0.83 (± 0.18) cm]. The diameter as well as the depth of the IJV increased with the age and weight of the patient.

CONCLUSIONS

This study demonstrates that the IJV is anterior or anterolateral to the artery in the majority of cases and that the anatomic relationship may change following the insertion of the LMA. It supports the need for using ultrasound-guided techniques for IJV cannulation following LMA insertion in spontaneously breathing children.

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.

The management of difficult intubation in children

This article looks at the current techniques and equipment recommended for the management of the difficult intubation scenario in pediatric practice. We discuss the general considerations including preoperative preparation, the preferred anesthetic technique and the use of both rigid laryngoscopic and fiberoptic techniques for intubation. The unanticipated scenario is also discussed.

A critique of elective pediatric supraglottic airway devices

In 1988, when the Laryngeal Mask Airway-Classic (Intavent Orthofix, Maidenhead, UK), was introduced there were only two choices of airway management: tracheal tube or facemask. The supraglottic airway, as we now understand the term, did not exist. Yet, 20 years later, we are faced with an ever increasing choice of supraglottic airway devices (SAD). For many SADs, with the exception of the LMA-Classic and LMA-Proseal (Intavent Orthofix, Maidenhead, UK), there is a lack of high quality data of efficacy. The best evidence requires a randomized controlled trial comparing a new device against an established alternative, properly powered to detect clinically relevant differences in clinically important outcomes. Such studies in children are very rare. Safety data is even harder to establish particularly for rare events such as aspiration. Therefore, most safety data comes from extended use rather than high quality evidence which inevitably biases against newer devices. For reason of these factors, claims of efficacy and particularly safety must be interpreted cautiously. This narrative review aims to present the evidence surrounding the use of currently available pediatric SADs in routine anesthetic practice.

Management of the upper airway and congenital cystic lung diseases in neonates

Congenital upper airway obstruction can pose difficult problems immediately after birth. Newer strategies to maintain the airway in such situations include pharyngeal ventilation, the laryngeal mask airway and flexible fibreoptic intubation. These methods have decreased the potential for malformations such as Pierre Robin sequence to cause perinatal hypoxia. The most devastating upper airway problem is total obstruction at the supraglottic, glottic or tracheal level without tracheo-oesophageal communication. This can usually be detected prenatally and its management may include the use of the EXIT (ex-utero intrapartum) procedure. Congenital space-occupying lesions of the lung can be detected prenatally with ultrasound. Their management must be individualised, as their pre- and postnatal development is difficult to predict. Very large lesions can lead to lung hypoplasia or fetal hydrops. Management may include prenatal surgery, shunting and, rarely, an EXIT procedure during birth. A few children may require extracorporeal membrane oxygenation postnatally.

Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway

For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.

Alternative airway devices for use in children requiring prehospital airway management: update and case discussion

This manuscript reviews the latest literature on alternative airways for use in children requiring prehospital airway management. Case discussions serve as a springboard for discussion of alternatives to bag-mask ventilation and endotracheal intubation for management of ventilation in infants and children in the prehospital setting. Few airway procedures have been studied with any rigor in this setting, and most of the data that are available are extrapolated from adults. Laryngeal mask airway may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider, but no controlled trial to date has been conducted.

Airway management in two of newborns with Pierre Robin Sequence: the use of disposable vs multiple use LMA for fiberoptic intubation

In this article, we discuss the use of LMAs as a conduit to intubate the trachea of two Pierre Robin Sequence infants. Multiple use LMAs will admit larger diameter tracheal tubes (TT) than their disposable counterparts. Increased friction with the surface of the TT makes passing even small diameter tubes through the lumen of the disposable LMA difficult.

[Airway management in pediatric anesthesia]

Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.

Anesthesia management for the child with Sanjad-Sakati syndrome

Sanjad-Sakati syndrome (SSS) is a rare genetic disorder characterized by congenital hypoparathyroidism, hypocalcemia and hyperphosphatemia, seizures, severe intrauterine and postnatal growth failure, dwarfism, mental retardation, dysmorphic features including retromicrognathia and abnormal dentition and increased susceptibility to infection. It is mainly confined to children in the Middle-East countries. We report the anesthesia management of a 12-year-old boy with SSS for dental treatment, and discuss the anesthesia implications of this disorder.

Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway

BACKGROUND

Induction of anesthesia and tracheal intubation in small children with a difficult airway is a challenging task. We report the experience with a procedure based on sevoflurane inhalation via a nasopharyngeal airway inserted early during induction before airway obstruction occurs. A pediatric fiberscope is used to perform a nasotracheal intubation via the opposite nostril.

METHODS

All small children with suspected or known difficult airway needing tracheal intubation were scheduled for a fiberoptic intubation following the described protocol.

RESULTS

In 3 years, we performed 27 successful fiberoptic guided tracheal intubations in 19 children, median age 8.2 months (1.0-39.1 months) and median weight 7.6 kg (3.0-15.0 kg). The optimal depth for placement of the nasopharyngeal airway was found to be 8.0 cm (7.0-8.5 cm) from the nostril in the first year of life and 8.5 cm (8.0-10 cm) in the second year. Oxygenation was sufficient during the entire procedure in all cases except one child who had short-lasting laryngeal spasm caused by instillation of lidocaine during light anesthesia. The duration of fiberoptic intubation was significantly shorter when performed by an experienced anesthesiologist (55 s vs. 120 s), but there was no significant correlation between the duration of fiberoscopy and oxygen saturation during fiberoscopy or endtidal CO(2) after intubation.

CONCLUSION

The combination of nasopharyngeal airway and fiberoptic guided tracheal intubation seems to be a reliable and safe procedure for managing the difficult airway in small children.

Anesthetic Considerations for the Obese and Morbidly Obese Oral and Maxillofacial Surgery Patient

The purpose of this article is to review the problems of anesthetic management of the obese patient and review current literature on this topic. Obesity is associated with a wide spectrum of medical problems. Anesthetic management requires being familiar with the pathophysiologic changes associated with obesity as well as the specific management issues that can arise. We will review recommendations from the literature on anesthesia management as they apply to the oral and maxillofacial surgeon.

Use of CobraPLA for airway management in a neonate with Desbuquois syndrome. Case report and anesthetic implications

We present the anesthetic management of an infant with Desbuquois syndrome (a rare form of micromelic dwarfism) with a possible difficult airway. The anesthetic implications of this syndrome are presented. The airway was managed with a new supraglottic device - the CobraPLA. Although intubation through this device was not possible in this instance, CobraPLA provided a satisfactory supraglottic airway. It was easy to insert and provided satisfactory conditions for positive pressure ventilation. The CobraPLA provides another option for airway management.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.