Additional Techniques for Managing the Difficult Pediatric Airway

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.

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.

Anesthesia for Treacher Collins syndrome: a review of airway management in 240 pediatric cases

OBJECTIVES

To review airway management with anesthesia for children with Treacher Collins syndrome (TCS) and determine whether intubation was more difficult with increasing age.

BACKGROUND

Treacher Collins syndrome is a rare disorder of craniofacial development characterized by maxillary, zygomatic, and mandibular dysplasia. TCS is associated with difficult intubation, but reports of airway management are limited to case reports and small cases series. Children with TCS may require multiple general anesthetics, and it has been suggested that intubation becomes more difficult with increasing age.

METHODS

A retrospective case note review of children with TCS from birth to 18 years undergoing anesthesia from 1971 to 2011 in a single center was performed. Demographic data, procedure type, anesthesia type, method of airway management, modified Cormack-Lehane (MCL) grade of laryngoscopic view, and any other descriptions of airway difficulty or complications were collated.

RESULTS

Of 59 patients with TCS, 35 children underwent a total of 240 anesthetics, most commonly for craniofacial surgery. Final airway management consisted of face mask 17%, laryngeal mask airway 16%, endotracheal intubation 49%, and 18% had a preexisting tracheostomy. The laryngeal mask airway provided an adequate airway in all cases when it was used. MCL grade was recorded in 97 cases involving 28 patients: 7% grade 1, 9% grade 2a, 31% grade 2b, 26% grade 3, and 27% grade 4. Fifteen (54%) patients were MCL grade 4 on at least one occasion. Failed intubation occurred in 6 (5%) of 123 cases of planned intubation. The procedure was canceled in two cases (0.8%) because of failure to intubate. Intubation techniques other than conventional direct laryngoscopy were used in 41% of cases. MCL grade increased with increasing age (P = 0.007).

CONCLUSIONS

Most children with TCS have difficult laryngoscopic views with many requiring specialized intubation techniques. Direct laryngoscopy becomes more difficult with increasing age. The laryngeal mask airway is a good choice of airway when endotracheal intubation is not required.

Resident training in advanced airway management

Management of the difficult airway is an essential skill that should be taught during an anesthesiology residency. However, only a minority of anesthesiology residency programs have formal rotations in advanced airway management. We developed a formal advanced airway rotation as an integral part of our residency program, consisting of two 1-month rotations during the residency, each with a separate focus. While on the advanced airway rotation, the resident anesthesiologist is given a set of objectives, a list of required reading, and a required number of procedures unique to advanced airway management that they must perform during the rotation. We believe that this rotation has been beneficial in improving the residents' exposure to advanced airway techniques, and has dramatically improved their capabilities in this important aspect of anesthetic of anesthetic training. Additionally, the structure of the rotation ensures uniformity in the residents' acquisition of advanced airway skills.