Prediction of difficult airway in school-aged patients with microtia

Kaban-Pruzansky Grade Predicts Airway Severity in Hemifacial Microsomia

BACKGROUND

Children born with hemifacial microsomia (HFM) can experience airway compromise. There is a paucity of data correlating degree of HFM severity with airway difficulty. This study aims to determine the relationship between the degree of micrognathia and airway insufficiency in the HFM population.

METHODS

Patient demographics, airway function, Kaban-Pruzansky (KP) grade, and Cormack-Lehane (CL) grade were collected and compared with appropriate statistics for HFM patients treated between 2000 and 2022.

RESULTS

Seventy patients underwent 365 operations with KP grading as follows: 34% KP grade I, 23% KP grade IIA, 11% KP grade IIB, and 33% KP grade III. Goldenhar syndrome was present in 40% of patients and 16% had bilateral disease. KP grade ( P < 0.001) predicted mean number of airway-affecting procedures undergone and difficult airway status ( P < 0.001), with 75% of difficult airways in KP grade III patients. There was no association of airway compromise with Goldenhar syndrome, laterality, or age ( P > 0.05). Most CL grades were I (61%) or IIA (13%), with fewer grade IIB, grade III, and grade IV (4% to 7%). KP grade predicted CL grade ( P < 0.001), with 71% of grade IV views and 64% of grade III views seen in KP grade III patients.

CONCLUSIONS

KP grade correlated with airway severity in HFM. Patients do not appear to outgrow their CL grade, as previously hypothesized, suggesting that KP grade III patients remain at increased risk for airway insufficiency into the teen years. Given the potential significant morbidity associated with airway compromise, proper identification and preparation for a challenging airway is a critical part of caring for patients with HFM.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Preliminary evaluation of SaCoVLM video laryngeal mask-guided intubation in airway management for anesthetized children

BACKGROUNDS

To preliminary evaluate the application of novel SaCoVLM video laryngeal mask -guided intubation for anesthetized children.

METHODS

One hundred twenty-four children with microtia (ages 5-15 years,) who required general intubation anaesthesia, were enrolled in the study. After induction of general anesthesia,guided tracheal intubation under direct vision of the SaCoVLM was performed. Our primary outcome was first-pass success rate of guided tracheal tube placement. Secondary outcome included glottic visualization grades, the first-attempt success rate of LMA placement, the time for LMA placement and time to endotracheal intubation as well as the time for LMA removal after successful intubation, the fiberoptic grade of laryngeal view, the baseline and postinduction hemodynamic parameters were also recorded,and the incidence 24 h complications after operation.

RESULTS

The first-pass success rate of guided tracheal tube placement was 91.1% (95%CI = 1.04-1.14), the status of glottic visualization was classified: grade 1 in 27cases, grade 2 in 36 cases, grade 3 in 41 cases and grade 4 in 20 cases. The first success rate of LMA placement was 92.7% (95%CI = 1.03-1.13), the time for LMA insertion was 15.7 (±9.1) s, intubation time was 30.9 (±17.6) s and withdrawl time was 24.9 (±9.3) s. The incidence of postoperative sore throat at 2 h was 29%, and 16.1% at 24 h, without dysphagia and hypoxia.

CONCLUSION

The SaCoVLM video laryngeal mask-guided intubation is feasible in children, with a high success rate, could be a new promising device to guide intubation in airway management.

TRIAL REGISTRATION

This study was approved by the University's Institutional Review Board and written informed consent was obtained from all subjects participating in the trial. The trial was registered prior to patient enrollment at clinicaltrials.gov (ChiCTR2200061481, http://www.chictr.org.cn . Principal investigator: Juan Zhi; Date of registration: 26/06/2022.

Intubation using video laryngeal mask airway SaCoVLM and laryngeal mask airway Ambu® Aura-i in anesthetized children with microtia: a randomized controlled study

The Ambu Aura-i laryngeal mask is considered to be a device for blind intubation as well as for fiberoptic guided intubation. The novel video laryngeal airway mask SaCoVLM is a supraglottic airway device that allows intubation under direct vision. We hypothesized that success rates for device placement and tracheal intubation with the SaCoVLM would be comparable with the Ambu Aura-i mask. A prospective, randomized clinical trial was conducted from March 2021 to December 2021. One hundred and twenty patients were enrolled and randomized in the study. Direct intubation was performed with the SaCoVLM, and fiberoptic guided intubation was performed with the Ambu Aura-i mask. The primary outcome measure was the first success rate of LMA placement. Secondary outcome measures were the time from device placement and time from endotracheal intubation (as well as the time for LMA removal after successful intubation), differences in airway leak pressure, fiberoptic grade of the laryngeal view, and incidence of blood staining. The first success rate of LMA placement was similar for the two devices. There was no difference in the time for successful endotracheal intubation between the Ambu Aura-i and SaCoVLM groups (24.1 s ± 6.3 versus 25.7 s ± 2.1; p > 0.05). The time for removal was slower in the SaCoVLM group than in the Ambu Aura-i group (20.8 s ± 0.8 versus 14.7 s ± 6.1; p < 0.01). The airway leak pressure was higher in the SaCoVLM group than in the Ambu Aura-i group (27.0 s ± 1.0 versus 22.3 s ± 3.6; p < 0.01), and the incidence of blood staining was higher in the SaCoVLM group (16.7%). The SaCoVLM has an overall comparable performance to the Ambu Aura-i mask. However, the SaCoVLM is better relative to direct intubation without the assistance of a flexible intubation scope, which reduces the device's demand.

Difficult airway prediction in paediatric anaesthesia (Diffair): Prospective observational study

BACKGROUND

The incidence of difficult airway in paediatric patients is lower than that the adult population, and the majority should be predictable.

AIMS

The primary aim of this trial was to evaluate the incidence of difficult airway in pediatric patients. The secondary aim was to predict difficult airway in these patients.

METHODS

Paediatric patients undergoing elective surgery under general anaesthesia in a tertiary university hospital were examined, and a panel of difficult airway prediction tests was performed. We recorded the incidence, risk factors for difficult airway and events associated with difficult airway together with the sensitivity and specificity of tests for difficult airway and events associated with difficult airway prediction.

RESULTS

We prospectively included 389 paediatric patients. The incidence of difficult airway was 3.6%; the incidence of events associated with difficult airway was 10%. The sensitivity for prediction of events associated with difficult airway during the pre-anaesthesia evaluation was 5.3% with the specificity 93.3%. In the operating room, the sensitivity of prediction was 15% with 97.8% specificity.

CONCLUSION

We found minimal efficacy for preanaesthesia difficult airway prediction.

Prediction of difficult laryngoscopy in school-aged patients with microtia

BACKGROUND

Children with microtia may experience difficult laryngoscopy because the ear and the mandible develop from the first and second bronchial arches and clefts.

METHODS

In this prospective observational study, we enrolled 166 patients (6-14 years old) with microtia scheduled for auricular reconstruction with autologous costal cartilage framework. Airway of the subjects was assessed preoperatively with the Modified Mallampati classification, Thyromental distance, Interincisor gap, Forward protrusion of the mandible and Horizontal length of the mandible. Anesthesiologist performed the direct laryngoscopy. Difficult laryngoscopy was classified as grade III or IV based on the Cormack-Lehane classification.

RESULTS

A total of 166 patients completed the study, including 158 (95%) isolated microtia patients and 8 (5%) hemifacial microsomia patients. The incidence of difficult laryngoscopy was 34/166 (20.5%) in all patients, 3/8 (37.5%) in hemifacial microsomia patients, 31/158 (19.6%) in isolated microtia patients (P=0.35). Multivariate logistic regression shows that Thyromental distance, Interincisor gap, Forward protrusion of the mandible are all independent predictors of difficult laryngoscopy. The sensitivity and specificity of each predictor were: Thyromental distance (82.35%, 89.39%), Interincisor gap (58.82%, 86.36%), and Forward protrusion (17.65%, 97.73%), respectively. The cutoff values of Thyromental distance and Interincisor gap for prediction of difficult laryngoscopy were 4.0 cm and 3.3 cm. The best combination of predictors was Thyromental distance/Interincisor gap/Forward protrusion of the mandible with a sensitivity of 94.12% and specificity of 86.36%.

CONCLUSIONS

The combination of Thyromental distance, Interincisor gap, and Forward protrusion of the mandible is the optimal assessment to predict difficult laryngoscopy in school-aged patients with microtia.

Preoperative anesthesia evaluation

The preoperative evaluation is the first step in ensuring the safe conduct of anesthetic care in pediatric patients of all ages. Over time, this process has changed significantly from a time when patients were admitted to the hospital the night before surgery to a time when the majority of patients, including those scheduled for major surgical procedures, arrive the day of surgery. For most patients, the preoperative examiantion can be conducted over the phone by a trained nurse or on-line via a survey thereby eliminating the need for a separate visit merely for the preoperative evaluation. Regardless of where or how it occurs, the goals of the preoperative evaluation are to gain information regarding the patient's current status, comorbid conditions, and the intended procedure. This process allows the identification of patients who require additional preoperative testing or those patients who need to be seen by an anesthesiolgoist prior to the day of surgery. During the preopeative evalaution, decisions are made regarding further laboratory or investigative work-up that are required. The preoperative meeting provides an arena to develop the initial parent-physcian rapport, outline anesthetic risks, and discuss the intended anesthetic plan including options for postoperative analgesia. The process facilitates the care of patients during the perioperative period while limiting surgical cancellations resulting from patient-related issues. The following chapter reviews the essential components of the preoperative evaluation including the appropraite use of preoperative laboratory testing and other investigative procedures including radiologic imaging. Key components of the physical examinatino including the airway examination are reviewed.

Management of the Difficult Airway in the Pediatric Patient

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.

Effect of availability of video laryngoscopy on the use of fiberoptic intubation in school-aged children with microtia

BACKGROUND

With the increasing popularity of video laryngoscopy during intubation of pediatric patients with normal or difficult airways, fiberoptic-assisted tracheal intubation, traditionally considered the gold standard for difficult intubation, may become underused.

AIM

We aimed to assess the use of airway management techniques before and after introduction of video laryngoscopy in a cohort of school-aged children with microtia, who are at increased risk of difficult intubation.

METHODS

We retrospectively reviewed intubation devices used for all pediatric patients with microtia who had undergone reconstructive ear surgery at a single institution during the period January 2008 to December 2012. In each case, we identified the original airway management technique and success rate, as well as success rate for subsequent rescue techniques. The use of fiberoptic-assisted tracheal intubation was compared before and after introduction of a pediatric blade for the Pentax-AWS video laryngoscope.

RESULTS

This study included 537 consecutive intubation procedures; 264 before and 273 after introduction of the pediatric airway scope. Elective use of fiberoptic-assisted tracheal intubation for anticipated difficult intubation was significantly less after introduction of the pediatric airway scope (before: 19 of 79, 24% vs after: 3 of 79, 4%; odds ratio 8.02; 95% confidence interval, 2.27 to 28.39; P = .0003), which achieved a 100% success rate when used as the primary technique in both routine and difficult airways. All 5 cases of failed direct laryngoscopy were rescued by the pediatric airway scope, thus eliminating emergency use of fiberscopy.

CONCLUSION

Introduction of a pediatric video laryngoscope resulted in a substantial decrease in the use of fiberoptic-assisted tracheal intubation. This change in intubation method might not influence the success rate of intubation in experienced hands but could be relevant for novice users.

Videolaryngoscopy in Neonates, Infants, and Children

Airway management is vital during anesthetic care and during resuscitative efforts in the PICU, the emergency department, and the delivery room. Given specific anatomic and physiologic differences, neonates and infants may be more prone to complications during airway management. Videolaryngoscopy may offer an alternative to or advantages over direct laryngoscopy in specific clinical scenarios. The following article reviews some of the basic types of videolaryngoscopy and discusses their potential applications in the pediatric population.

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.

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.

Sleep outcomes in children with hemifacial microsomia and controls: a follow-up study

OBJECTIVE

Children with craniofacial anomalies are at high risk for sleep-disordered breathing (SDB), yet its prevalence among children with craniofacial conditions is not known. Children with hemifacial microsomia (HFM) are likely particularly vulnerable to SDB as a result of underdevelopment of the mandible and oropharynx. Nevertheless, most children with HFM are not referred for sleep studies. We hypothesized that sleep outcomes would be worse in children with HFM versus control subjects.

METHODS

We conducted a follow-up study among 124 case participants and 349 control subjects who previously participated in a study of HFM risk factors. Parents completed the Pediatric Sleep Questionnaire (PSQ) regarding symptoms of SDB and sleep habits. Regression models were adjusted for region, age, sex, race/ethnicity, and maternal education.

RESULTS

Snoring was more commonly reported for children with HFM (29%) than for control subjects (17%). Compared with control subjects, children with HFM more often had symptoms consistent with SDB. On average, case participants' parents reported 1.9 times as many symptoms on the PSQ breathing scale and 1.3 times more symptoms on the PSQ sleepiness scale than did control subjects' parents, with little difference on the PSQ behavior scale. Parents of children with HFM reported 1.4 times more night awakenings than did control subjects' parents.

CONCLUSIONS

Children with HFM experienced more snoring and other symptoms of SDB than did control subjects. Pediatricians should be aware of the increased vulnerability for SDB among children with mandibular or external ear underdevelopment or asymmetry and should refer to a sleep specialist as needed.

[Difficult tracheal intubation in paediatric: myth or reality?]

Difficult tracheal intubation is a rare event according to the airway feature in child. This situation is mostly predictable, occurring in identified malformations and in specific diseases. Pre-operative clinical evaluation must detect facial abnormalities (lip or palate cleft, microtia, facial asymmetry.), micro or retrognathia, limited mouth opening, reduced distance between thyroid cartilage and chin, macroglossia and external ear malformations. According to this clinical evaluation, a strategy for managing difficult tracheal intubation is planned.