Nasal high‐flow oxygen in pediatric anesthesia and airway management

Nasal High‐Flow (NHF) is weight‐dependent in children, aimed to match peak inspiratory flow and thereby deliver an accurate FiO₂ with a splinting pressure of 4‐6 cm H₂O. During apnea in children, NHF oxygen can double the expected time to desaturation below 90% in well children but there is no ventilatory exchange; therefore, children do not “THRIVE”. Total intravenous anesthesia competency to maintain spontaneous breathing is an important adjunct for successful NHF oxygenation technique during anesthesia. Jaw thrust to maintain a patent upper airway is paramount until surgical instrumentation occurs. There is no evidence to support safe use of NHF oxygen with LASER use due to increased risk of airway fire.     

The normal and the challenging pediatric airway

Management of a child’s airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists’ repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted – the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of ‘cannot ventilate, cannot intubate’ in children.     

Visual aids for pediatric airway management

Four basic types of visual aids are used for teaching airway management and decision‐making in simulated as well as in real clinical situations: universal algorithms, sets of limited algorithms, concept‐based cognitive aids, and checklists. The first three may represent an evolution in the understanding of the role of human error in both successful and failed airway management. Complex visual aids such as the American Society of Anesthesiology difficult airway algorithm may be more useful for teaching, while graphic cognitive aids like the Vortex may be more helpful for decision‐making under stress. Not surprisingly, there is a lack of outcome studies, although some cognitive aids have been evaluated in simulation settings.     

Awake GlideScope intubation in a critically ill pediatric patient

We report a challenging case of a 10‐year‐old boy with history of biventricular heart failure, pulmonary hypertension, severe asthma, and obesity with a BMI of 37. He presented to our hospital in acute decompensated heart failure. Our anesthesia team was consulted by the pediatric intensivist for urgent airway management in this rapidly deteriorating, premorbid patient. We describe here the use of the GlideScope^® in an awake pediatric patient of ASA 4E status with a potentially difficult airway who required to remain in the seated position and thus necessitating a face‐to‐face approach.     

Anaesthesiological airway management in Denmark: assessment, equipment and documentation

BACKGROUND: Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management. METHODS: Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark. RESULTS: Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available. CONCLUSION: The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.     

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 impact of respiratory protective equipment on difficult airway management: a randomised,crossover, simulation study

The current international COVID-19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air-purifying respirators and powered air-purifying respirators during simulated difficult airway scenarios. Twenty-five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.     

New options for airway management: intubating fibreoptic stylets

Br J Anaesth 2003; 91: 408–18     

Surgical approach in difficult airway management

In all difficult airway algorithms, cricothyroidotomy is the life-saving procedure and is the final 'cannot ventilate, cannot intubate' option, whether in pre-hospital, emergency department, intensive care unit, or operating room patients. Cricothyroidotomy is a relatively safe and rapid means of securing an emergency airway. As with all other critical procedures in emergency medicine, a thorough knowledge of the technique and adequate practice prior to attempting to perform an emergency cricothyroidotomy are essential.     

Management of an unusual pediatric difficult airway using ketamine as a sole agent

We present the case of a 9-year-old boy who suffered a fall while brushing his teeth. This resulted in impalement of the lateral pharyngeal wall by the toothbrush with its head becoming firmly lodged adjacent to the internal carotid artery as demonstrated by CT scan. The length of the toothbrush protruding from the mouth and the inability to adequately assess the airway prior to any intervention gave rise to a unique set of surgical and anesthetic airway management problems. These were compounded by the possibility of damage to the carotid artery and potential catastrophic hemorrhage with manipulation of the toothbrush at any point. We detail the problems and outline our management.     

A history of pediatric anesthesia: a tale of pioneers and equipment

The history of pediatric anesthesia is fascinating in terms of how inventive anesthesiologists became over time to address the needs for advances in surgery. We have many pioneers and heroes. We hope you will enjoy this brief overview and that we have not left out any of the early contributors to our speciality. Obviously there is insufficient space to include everyone.     

Pediatric airway management: current practices and future directions

Management of a pediatric airway can be a challenge, especially for the nonpediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra‐glottic devices for maintaining ventilation, and introduction of pediatric versions of new ‘non line of sight’ laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.     

The performance of rigid scopes for tracheal intubation: a randomised,controlled trial in patients with a simulated difficult airway

We compared the Bonfils^? and SensaScope^? rigid fibreoptic scopes in 200 patients with a simulated difficult airway randomised to one of the two devices. A cervical collar inhibited neck movement and reduced mouth opening to a mean (SD) of 23 (3) mm. The primary outcome parameter was overall success of tracheal intubation; secondary outcomes included first‐attempt success, intubation times, difficulty of intubation, fibreoptic view and side‐effects. The mean (95% CI) overall success rate was 88 (80–94)% for the Bonfils and 89 (81–94)% for the SensaScope (p = 0.83). First‐attempt intubation success rates were 63 (53–72)% for the Bonfils and 72 (62–81)% for the SensaScope (p = 0.17). Median (IQR [range]) intubation time was significantly shorter with the SensaScope (34 (20–84 [5–240]) s vs. 45 (25–134 [12–230]) s), and fibreoptic view was significantly better with the SensaScope (full view of the glottis in 79% with the SensaScope vs. 61% with the Bonfils). This might be explained by its steerable tip and the S‐formed shape, contributing to better manoeuvrability. There were no differences in the difficulty of intubation or side‐effects.