Preoperative predictors of poor laryngoscope views in pediatric population undergoing cardiac catheterization

Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features

Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

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.

Evaluation of various anthropometric airway parameters as predictors of difficult airway in neonates: A prospective observational study

OBJECTIVE

To determine the relationship between various anthropometric parameters (age, weight, neck circumference, head circumference, thyromental distance, sternomental distance, frontal plane to chin distance, and frontal plane to chin distance by weight ratio) in neonates with difficult laryngoscopy and difficult intubation.

DESIGN

A Prospective, double-blind, observational study.

SETTING

Conducted in a Tertiary care Hospital in India. The study was conducted over a period of one year.

PATIENTS

Participants included 100 neonates undergoing either elective or emergency non-cardiac surgery under general anesthesia.

INTERVENTIONS

The various anthropometric parameters were correlated with Difficult laryngoscopy (Cormack Lehane grading III, IV) and Difficult intubation (Intubation Difficulty score>5).

MEASUREMENTS

Difficult laryngoscopy (Cormack lehane grade III, IV) and Difficult intubation (Intubation Difficulty score >5).

MAIN RESULTS

We found a statistically significant difference between weight (2.5 (2.2-2.8) kg vs 1.9 (1.55-2.35) kg), (p = 0.006), TMD (3.03 (2.74-3.46) cm vs 2.70 (2.45-3.13) cm), (p = 0.029), SMD (5.18 (5.06-5.76) cm vs 5.02 (4.84-5.29) cm), (p = 0.020) and FPCD/Wt ratio (0.31 (0.27-0.36) vs 0.44 (0.37-0.44)) with p = 0.001 in neonates with Easy and Difficult laryngoscopy. Using ROC curve analysis we calculated AUC, optimal cut off value, sensitivity, specificity, PPV and NPV for weight, TMD, SMD and FPCD/Wt ratio and found FPCD/Wt ratio to be best predictor for difficult laryngoscopy with highest AUC (0.844), high sensitivity (77.78%) and NPV (97.44%).

CONCLUSIONS

No single parameter can provide a high index of sensitivity and specificity to predict difficult airway in neonates. Therefore, a combination of tests, including Weight, TMD, SMD, and FPCD/Wt ratio, should be used. To the best of our knowledge, this is the first prospective study to assess predictors to the difficult airway in neonates.

Evaluation of the relationship between airway measurements with ultrasonography and laryngoscopy in newborns and infants

BACKGROUND

A difficult laryngoscopy in young children can be a stressful situation for the pediatric anesthetist. In recent years, several measurements have been used to obtain difficult laryngoscopy markers in children. However, there is no prospective study in which ultrasonography is expected to be used for this purpose, particularly in the newborn and infant age groups.

GOALS

In this study, our goal was to evaluate the relationship between the preoperative airway assessment tools and the difficult laryngoscopic view in neonates and infants.

METHODS

Our study included newborns and infants undergoing elective surgery requiring intubation under general anesthesia. The following measurements were recorded the following: patients' age, body mass index, thyromental distance, mandibular length, the distance between the lip corner and ipsilateral ear tragus, and the transverse length (measured by hand with sign-middle-ring fingers side by side). In the thyromental distance measurement, the "thyroid notch" was determined by ultrasonography. Glottic structures appearing during laryngoscopy were graded according to the Cormack-Lehane Classification.

RESULTS

Of the 150 patients included in the study, 36 were female, and 92% were under the age of one. The incidence of difficult laryngoscopic views was 8% in the age groups studied, and the frequency of difficult laryngoscopic views in the newborn age group was 14.3%. The relationship between airway assessment tools and the Cormack-Lehane Classification scores was statistically significant. The negative predictive value was high for all values.

CONCLUSIONS

The risk of a difficult laryngoscopy increases in children under the age of one. The preoperative airway assessment tools and body mass index had acceptable negative predictive values. We believe that all measurements could be used as markers for difficult laryngoscopy in newborns and infants.