- 6th Anesthesia & Critical Care Conference

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Transcript - 6th Anesthesia & Critical Care Conference

Predicting the Pediatric
Difficult Airway
Maria Matuszczak M.D.
Division Chief Pediatric Anesthesia
Department of Anesthesiology UT Houston
to Disclose
• Incidence of pediatric difficult airway
• Anatomical and physiological differences of the
pediatric airway
• Indicators of a pediatric difficult airway
• Embryology of the airway
• Evaluating the difficult pediatric airway
Ultimate Goal of
Predicting the Difficult
Predicting the difficult laryngoscopic intubation: are we on the right track?
Editorial ; M. Murphy et al. CAN J ANESTH 2005,52:3;231-35
Airway and respiratory complications
most common causes of
anesthesia related morbidity
Frequently occur in healthy children
Failure to perform an adequate evaluation of the
can lead to catastrophic outcome
An update on pediatric anesthesia liability: closed claim analysis. N.Jimenez et al. Anesth
Analg 2007;104(1):147-53
Laryngospasm, failure to ventilate, failure to intubate
Anesthesia-related Cardiac Arrest in Children
Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA)Registry
Jeffrey P. Morray, M.D., Anesthesiology 2000,93:6-14
(20% of cardiac arrest du to respiratory events in healthy children)
Perioperative cardiac arrest and its mortality in children.
A 9-year survey in a Brazilian tertiary teaching hospital
Leandro Gobbo Braz M.D.,Pediatr Anesth 2006,16:860-66
(71.5% of cardiac arrest du to respiratory events)
Paediatric perioperative cardiac arrest and its mortality:
database of a 60-month period from a tertiary care paediatric center
Neerja Bharti,M.D., Eur J Anaesth 2009,96(5):490-5
(56% of cardiac arrest du to respiratory events)
Cardiac arrest in anesthetized children:
recent advances and challenges for the future
Jeffrey P. Morray, M.D., Pediatr Anesth 2011,21:722-29
(decrease of cardiac arrest, but not for <1 year of age, risk /age)
Critical incidents and mortality reporting in pediatric anesthesia:
the Australian experience
Review of critical events
Phiilip Ragg MD, Pediatr Anesth 2011,21:754-57
(WebAIRS: Respiratory and Airway critical events 21% , top of a 9 category list)
Major Complications of airway management in the UK, NAP4
T.M.Cook et al. Br J Anaesth 2011, 106(5) 617-31 and 632-42
( ten events in children < 10-yr, 5 infants, 3 deaths)
Pediatric difficult
airway registry
Predicting the difficult laryngoscopic intubation:
are we on the right track?
Editorial ; M. Murphy et al. CAN J ANESTH 2005,52:3;231-35
able to oxygenate via bag mask ventilation
able to ventilate via SGD
able to intubate
able to secure a surgical airway
Different Assessment in Different Situations
Planned surgery
Emergency department
Code on the floor
The pediatric patient
Most often not cooperative for evaluation
“Awake” fiberoptic intubation ???
Deep sedation or GA often needed to proceed
Evaluation of laryngoscopic views and related influencing factors in a pediatric population
Asadollah Mirghassemi, M.D. Pediatr Anesth 2011; 21: 663-667
Cross-sectional study, Iran
511 consecutive pediatric patients requiring ETT
No known airway abnormality
Age 0.5-13 years old, mean age 18 month
Distance nose to upper lip,
lower lip to mentum,
ear tragus to mouth
horizontal length of mandible
thyromental distance, were measured
Cormack& Lehane classification
Results: difficult laryngoscopy,
16.4% in neonates
2.6% in >1 months - <5 years of age
0% in > 5 years of age
distance lower lip to mentum,
and ear tragus to mouth were
associated with difficult intubation,
but no cut off
COPUR way score
• C = Chin. • O = Oral opening. • P = Previous Intubations, Past History. • U = Uvula
(Mallampati Score). • R = Range.
Modifiers: mucpolysaccaridoses, morbid obesity, ―buck teeth‖, large tongue
Anatomic differences between pediatric and adult airways
Large head and prominent occiput
Hypertrophied lymphoid tissue
Long epiglottis
The pediatric airway W.L. McNiece, S.F. Dierdorf, Semin Ped Surg 2004;13(3): 152-65
Nose breather
Small nasal passage
Large tongue
Larynx more anterior, cephalad, located at C2-3
instead of C4-5
Small and short trachea
Pediatric airway is highly compliant
Cartilaginous support less developed
Increased susceptibility to dynamic airway collapse
Laryngeal structures more pliable, less rigid
By the age of 8, airway similar to adult airway
Respiratory physiologic differences
between children and adults
respiratory rate
chest wall compliance
lung elastic recoil ( lung compliance)
functional residual capacity
rate of oxygen consumption
Findings that predict the presence of a difficult
airway in children
Limited mouth opening,
small mouth
Large tongue, lingual tonsils
Prominent central incisor,
Mandibular hypoplasia
Findings that predict the presence of a difficult airway in children
Laryngeal edema (infection, inhalation injury)
Hemangioma of the lip
Facial or hemi-facial anomalies
Malformation of the ear
Findings that predict the presence of a difficult airway in children
Mandibular, mid-face, and facial trauma
Cervical spine immobility (immobilization, trauma,
congenital malformation)
Short neck, obesity,
Obstructive sleep apnea
Findings that predict the presence of a difficult airway in
Congenital hydrocephalus
Tracheal stenosis
Tumor/ Foreign body
Metabolic and Dysmorphic Syndromes
Impressive list of syndromes associated with difficult airway:
4p-, 5p- ( cri du chat), 9p-, 11q-, 13q-syndrome, Achondro-gensis, -plasia, Apert, Arnold-Chiari,
Arthrogryposis, Beckwith-Wiedemann, c-Syndrome, Carpenter, CHARGE, Cockayne, Cornelia de
Lange, Crouzon, DiGeorge, Down, Dutch-Kentucky, Dwarfism, Epidermolysis Bullosa, Fabry
Disease, Farber Disease, Fibrodysplasia Ossificans Progressiva, Fraser Syndrome, FreemanSheldon, FrontometaphysealDysplasia, Fryns, Goldenhar, Goltz, Gorham, Hajdu-Cheney,
Hallermann-Streiff, Holoprosencephaly Sequence, Hunter (Mucopolysaccharidosis II), Hurler
(MucopolysaccharidosisIH), Hurler-Scheie (Mucopolysaccharidosis I H/S), I-Cell Disease,
Ichthyosis, Johanson-Blizzard, Juvenile Hyaline Fibromatosis, Kippel-Feil Sequence, Kniest,
Larsen, Lipoid Proteinosis,Maroteaux-Lamy, Marshall-Smith, Meckel-Gruber, MelkerssonRosenthal, Menkes-Kinky-Hair, Metaphyseal Chondrodysplasia Jansen, Moebius, Morquio,
Nager, Nemaline Rod Myopathy, Neurofibromatosis, Noonan, Opitz, Osteogenesis Imperfecta,
Pfeiffer, Pierre-Robin, Pompe Disease, Popliteal Pterygium, Potter, Proteus, ………………………
Just to name some of them
Difficult intubation in paediatrics. F. Frei et al. Paediatr Anaesth 1996;6:251-63
Treacher Collins
Embryology of the pediatric airway
Branchial Arches
1. future mandible, middle ear bones, malleus, incus
2. stapes, styloid process and ligament, portion of hyoid bone
3. and 4. inferior portion of hyoid and thyroid cartilage
Branchial Pouches
1. Auditory tube and middle ear cavity
2. Part of tonsillar fossa, lymphoid tissue
3. and 4. parathyroid and thymus
Branchial Clefts
1. External ear
Anatomy and assessment of the pediatric airway. L. Adewale , Pediatr Anesth 2009; 19(s.1):1-8
1. able to oxygenate via bag mask ventilation
2. able to ventilate via SGD
3. able to intubate
4. able to secure a surgical airway
Predicting the difficult laryngoscopic intubation: are we on the right track? M. Murphy et al.
CAN J ANESTH 2005,52:3;231-35
able to oxygenate via bag mask ventilation
Medical history !
Obesity/ OSA/day time fatigue,
Noisy breathing/stridor/phonation/feeding
Upper airway infection/cough/fever
Normal facies, lateral view
Tumor, abscess, trauma
able to ventilate via SGD
Medical history
Mouth opening
Normal facies
Neck mobility
able to intubate
Medical history
Noisy breathing
Mouth opening
Neck mobility
Normal facies, especially lateral view
Thyreo-mental distance in older children
Ischemic subglottic damage following a short-time intubation.
Marta Joao Silvaa et al. European Journal of Emergency Medicine 2008, Vol 15 ( 6)
able to secure a surgical airway
Neck anatomy/mobility
Palpate cricoid membrane in older children
Have ENT/surgeon available
Have ultrasound available
Difficult Airway Evaluation
ASA difficult airway algorithm
Imaging of the Airway and other exams
Lung function tests
Sleep studies
Anesthetic management of lingual thyroglossal duct cyst in an infant with stridor.
H.V.Lauro et al. Abstract presented at IARS meeting , Vancouver 2011
Use of Sonography for Airway Assessment
An Observational Study
Mandeep Singh,M.D., J Ultrasound Med 2010;29:79-85
Prediction of Pediatric Endotracheal Tube Size by Ultrasonography
M. Shibasakiet al.,Anesthesiology 2010; 113(4) ; 819-24
Assessment in the emergency situation
Need to be fast
No time to come back another day
Assessment in the emergency situation
Respiratory distress is 4th most common chief
complaint in children presenting to the
emergency department.
Peak age of respiratory distress is under 2years
of age, an age at which the airway is significantly
different from the adult.
Assessment in the emergency situation
Appearance of child
Work of breathing
Noisy breathing/stridor/voice/cry
Body position
Normal facies
Neck mobility
Predicting the fetal difficult airway
Antenatally diagnosed congenital airway obstruction
Important information from Fetal MRI
Exit procedure with multidisciplinary management
If undiagnosed: potential for fatal outcome
Four Cases of Congenital Airway Obstruction: Optimizing Perinatal management
H.McDevitt, M.D., Acta Paediatr. 2007;96(10):1542-5
Optimal outcomes with pediatric airway
management require a thorough
understanding of the physiologic, and
anatomic differences between children and
Additionally difficult airway recognition, good
preparation, and familiarity with back-up plans
for airway management are essential.
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