A clinical prediction rule to identify difficult intubation in children with Robin sequence requiring mandibular distraction osteogenesis based on craniofacial CT measures

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.

An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists

BACKGROUND

Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS.

METHODS

For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded.

RESULTS

A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating.

CONCLUSIONS

Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.

Comparison of Glidescope Core, C-MAC Miller and conventional Miller laryngoscope for difficult airway management by anesthetists with limited and extensive experience in a simulated Pierre Robin sequence: A randomized crossover manikin study

BACKGROUND

Video laryngoscopy is an effective tool in the management of difficult pediatric airway. However, evidence to guide the choice of the most appropriate video laryngoscope (VL) for airway management in pediatric patients with Pierre Robin syndrome (PRS) is insufficient. Therefore, the aim of this study was to compare the efficacy of the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a nonangulated Miller blade (C-MAC® Miller) and a conventional Miller laryngoscope when used by anesthetists with limited and extensive experience in simulated Pierre Robin sequence.

METHODS

Forty-three anesthetists with limited experience and forty-three anesthetists with extensive experience participated in our randomized crossover manikin trial. Each performed endotracheal intubation with the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a Miller blade and the conventional Miller laryngoscope. "Time to intubate" was the primary endpoint. Secondary endpoints were "time to vocal cords", "time to ventilate", overall success rate, number of intubation attempts and optimization maneuvers, Cormack-Lehane score, severity of dental trauma and subjective impressions.

RESULTS

Both hyperangulated and nonangulated VLs provided superior intubation conditions. The Glidescope® Core™ enabled the best glottic view, caused the least dental trauma and significantly decreased the "time to vocal cords". However, the failure rate of intubation was 14% with the Glidescope® Core™, 4.7% with the Miller laryngoscope and only 2.3% with the C-MAC® Miller when used by anesthetists with extensive previous experience. In addition, the "time to intubate", the "time to ventilate" and the number of optimization maneuvers were significantly increased using the Glidescope® Core™. In the hands of anesthetists with limited previous experience, the failure rate was 11.6% with the Glidescope® Core™ and 7% with the Miller laryngoscope. Using the C-MAC® Miller, the overall success rate increased to 100%. No differences in the "time to intubate" or "time to ventilate" were observed.

CONCLUSIONS

The nonangulated C-MAC® Miller facilitated correct placement of the endotracheal tube and showed the highest overall success rate. Our results therefore suggest that the C-MAC® Miller could be beneficial and may contribute to increased safety in the airway management of infants with PRS when used by anesthetists with limited and extensive experience.

Predictor of postoperative dyspnea for Pierre Robin Sequence infants

The aim of this retrospective study is to determine the predictive factors of postoperative dyspnea in infants with Pierre Robin sequence (PRS). Forty children with PRS, who underwent general anesthesia, were retrospectively analyzed. The patient’s physiological status and anesthesiology data were collected accordingly, demographic characteristics including age, gender, height and weight at surgery, weight gain, preoperative airway status, tracheal intubation route, American Society of Anesthesiologists grading and airway Cormack–Lehane classification. Weight gain, dyspnea before the operation, Cormack–Lehane grade distribution showed a significant difference between patients with and without postoperative dyspnea (p = 0.0175, p = 0.0026, and p = 0.0038, respectively). Incompetent weight gain was identified as a predictor (p = 0.0371) of PRS postoperative dyspnea through the binary logistic regression model. In conclusion, this study established an early alerting model by monitoring the weight gain, dyspnea before the operation, Cormack–Lehane grade as potential combinations to predict the risk of postoperative dyspnea for PRS.