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INTRODUCTION

FOCUS POINTS

  1. Knowledge of proper supraglottic airway insertion techniques, tests for position and performance, and maneuvers to correct malpositions are critical to successful use and the prevention of complications.

  2. Video laryngoscopy provides better views of the glottis compared to direct laryngoscopy, although intubation times may be prolonged. Skill acquisition in elective cases before use in complex difficult airway situations is recommended. Corrective maneuvers in the “Can see, can’t intubate” situation must be learned.

  3. Difficult airway management in pediatric patients is associated with a high incidence of severe complications. Risk factors for complications are: greater than two laryngoscopy attempts, direct laryngoscopy persistence (direct laryngoscopy for first three attempts), and weight under 10 kg.

  4. Supplemental oxygenation during pediatric difficult airway management is an important intervention that may reduce the incidence of severe complications.

  5. Fiberoptic intubation in the small infant is challenging and requires great attention to every detail. Practicing this technique in elective normal airways is likely to result in greater rate of successful intubation when faced with a difficult airway.

  6. Adequate preparation and planning decreases the need for surgical airway access. Use of a small angiocatheter technique is the preferred initial approach for front of neck access in children 1 to 8 years of age.

  7. Simple airway maneuvers such as two-handed mask ventilation and adjunctive airway devices are critical in management of the difficult pediatric airway.

SUPRAGLOTTIC AIRWAY DEVICES

Supraglottic airway devices (SGAs) are devices with a ventilation opening(s) located above the glottis. Other terms that have been used include extraglottic airway devices (EADs) and periglottic airway devices (PADs). Supraglottic airway devices have also been abbreviated as SADs, but this usage is less common than SGAs. In general, SGAs may be considered a hybrid device between a face mask and an endotracheal tube (ETT). Over 30 devices are currently on the market but only a few of these are clinically useful in pediatric patients.

CLASSIFICATION OF SGAs

SGAs may be classified by brand type or by degree of sophistication.1 The Laryngeal Mask Airway™ is the first brand and remains the most commonly used brand. Since its development in the late1980s, several brands have been developed and are increasingly being used in anesthetic practice (Figure 27-1). Other brands are classified as the non-LMA™ family of devices.

Figure 27-1

Supraglottic airway devices. Left to right: LMA Classic, LMA Flexible with Cuff pilot valve, LMA Flexible PVC, LMA Unique, Cobra Perilaryngeal Airway, LMA Unique Silicone Cuff, Ambu Aura-i laryngeal mask, Air-Q ILA, LMA ProSeal, LMA Supreme, i-gel, Ambu AuraGain, LMA Protector, LMA Gastro. (Used with permission, from Dr. Patrick N. Olomu, University of Texas Southwestern Medical Center/Children’s Health System of Texas - Dallas.)

First-generation devices are basic airway tubes, consisting essentially of a mask bowl, an airway tube, ...

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