Chapter 128: Pediatric Airway Management

INTRODUCTION

The approach to a pediatric airway should be systematic and well planned. Steps to be taken in proper airway management include clinical assessment, preparation of equipment and staff, and a series of interventions designed to address the clinical condition of the patient. A good foundation of understanding of pediatric airway is necessary for appropriate airway management including anatomy and respiratory physiology, head and neck positioning, depth of anesthesia, correct methods of opening of airway, and proper bag-mask ventilation.

Uninterrupted oxygenation and ventilation require meticulous attention to facemask ventilation and intubation. A majority of pediatric patients can be successfully ventilated with facemask or supraglottic devices and intubated with ease. A difficult airway (DA) may occasionally be encountered and alternative methods of oxygenation and ventilation should be available if facemask ventilation or intubation fails. Many craniofacial and congenital abnormalities are associated with DA management. History of trauma to face and neck, neck and airway tumors, foreign-body aspiration present DA challenges and alternative methods of providing ventilation and intubation should be planned in advance.

ASSESSMENT OF THE PEDIATRIC AIRWAY

History

The pediatric airway history should include an assessment of the following potential problems:

• Upper respiratory infections predispose the child to coughing, laryngospasm, bronchospasm, and desaturation during anesthesia or to postintubation subglottic edema or postoperative desaturation.

• Snoring or noisy breathing may signify adenoid or tonsillar hypertrophy, upper airway obstruction, obstructive sleep apnea, or pulmonary hypertension.

• Cough—A “croupy” cough may indicate subglottic stenosis or previous tracheoesophageal fistula repair. A productive cough may indicate bronchitis or pneumonia. The chronicity of the cough affects the differential diagnosis (e.g., the sudden onset of a persistent cough may indicate foreign-body aspiration).

• Croup, either postintubation croup or presence of subglottic stenosis.

• Repeat episodes of pneumonia are suggestive of an incompetent larynx with aspiration, gastroesophageal reflux, cystic fibrosis, bronchiectasis, residual tracheoesophageal fistula, pulmonary sequestration, immune suppression, or congenital heart disease.

• Foreign-body aspiration predisposes to increased airway reactivity, airway obstruction, and possible impaired neurologic function.

• Aspiration of gastric contents predisposes to laryngeal edema and may be suggestive of a laryngeal cleft.

• Atopy or allergy may lead to increased airway reactivity.

• Smoking by primary caregivers may lead to increased airway resistance and increased propensity to desaturation.

• Congenital syndrome such as choanal atresia, Treacher Collins syndrome, Goldenhar or Pierre Robin sequence may include associated cleft lip and palate and mandibular hypoplasia.

• Atlantoaxial instability in a patient with Down’s syndrome should be documented.

Physical Examination

The pediatric pulmonary examination should include an assessment of the following potential problems:

• Inspiratory stridor, usually high pitched, indicates subglottic narrowing, laryngomalacia, macroglossia, laryngeal web, extrathoracic foreign body, or extrathoracic tracheal compression.

• Hoarseness or changes in voice from laryngitis, vocal cord palsy, papillomatosis, or granuloma.

• Bronchospasm or wheezing due to asthma and bronchodilator therapy.

• Presence or absence of suprasternal, intercostal, ...