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A newborn with small bowel obstruction is taken to the operating room for an exploratory laparotomy. You are called to assist with a potentially difficult airway. Initial assessment of the newborn demonstrates a “small chin” and obvious signs of respiratory distress including tachypnea and upper airway obstruction. The baby’s oxygen saturation is 91% in the supine position. The primary anesthesia practitioner suggests an “awake” intubation in light of the potential for aspiration and high likelihood of a difficult airway.


When I See the Patient for the First Time, What Should I Be Looking for?

A thorough assessment of the patient’s anatomic features can yield significant information. Features associated with a difficult airway include a narrow inter-incisor distance, restricted head extension, mandibular hypoplasia, midface hypoplasia, macroglossia, and microstomia.1,2 Furthermore, it is important to determine whether the patient has been diagnosed with any syndromes. One study showed that half of the patients with difficult intubations were diagnosed with a syndrome, and the other half had extremely anterior airways and micrognathia.3 Another large study identified that micrognathia, a weight less than 10 kg, greater than two tracheal intubation attempts, and three direct laryngoscopy attempts before an indirect technique were independently associated with an increased risk of severe airway complications.4 It is important to evaluate the patient while lying supine at rest to look for signs of upper airway obstruction, such as paradoxical chest wall movement and/or stridor while observing for any changes in oxygen saturation.

What Are Some of the Most Common Syndromes Associated with a Difficult Airway?

There are several syndromes that are well known to be associated with a difficult airway (see Chapter 46). Each syndrome presents its own functional or anatomic challenge. Classic examples include Pierre Robin sequence (micrognathia), Treacher Collins (mandibular hypoplasia), Goldenhar syndrome (mandibular hypoplasia), Hunter’s and Hurler’s syndromes (mucopolysaccharidoses) and more.1 It is important to be familiar with these syndromes as these patients may be at risk for difficult face-mask ventilation (FMV), difficult intubation, or both.5


When Should I Consider Doing an Awake Intubation in a Neonate?

An awake intubation should be strongly considered in a neonate if there is a clinical picture suggestive of difficult FMV, difficult laryngoscopy and intubation, or high aspiration risk with severe upper airway obstruction at rest.6 Awake patients have the ability to maintain their own life-saving oxygenation and ventilation and are more able to protect themselves from aspiration of regurgitant gastric contents. One airway algorithm to help guide clinical decision-making is listed in Figure 51.1.7


A useful airway algorithm to help guide clinical decision-making.

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