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Chapter 169. Pediatric Difficult Airway

Wanda A. Chin, MD

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Initial Airway Assessment
HistoryDoes this child have a history of airway distress or difficult airway management?Evaluate for Hx of stridor, dyspnea, FTT, previous anesthetics, OSA
Physical exam

Is there current active airway distress?

Does the patient have any dysmorphic features?

Note level of airway distress and features such as micrognathia, high arched palate, choanal atresia, decreased mouth opening
Special studiesWill further workup help to formulate a plan?CT scans, laryngoscopies, sleep studies
Patient maturityCan patient cooperate with airway management?Emotionally, psychologically, or intellectually
Surgical procedureWhat is needed for this procedure?
  • Regional versus general
  • Mask versus LMA versus ETT versus surgical airway

  • Larynx higher in neck
  • Narrowest part of airway is cricoid
  • Epiglottis stiffer, larger, and more posterior
  • Tongue disproportionately larger
  • Short neck
  • Head/occiput larger relative to body size

See Figure 169-1.

Figure 169-1. Pediatric Difficult Airway Flow Diagram
image
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  • Assess the likelihood of management problems:
    • Difficult ventilation
    • Difficult intubation
    • Difficult patient cooperation
    • Difficult surgical airway
  • Provide supplemental oxygen
  • Consider basic management choices:
    • Surgical airway versus noninvasive airway
    • Awake intubation versus intubation after induction: Most pediatric patients will lack the maturity to cooperate for awake intubation and intubation attempts are performed after induction of general anesthesia
    • Spontaneous ventilation versus ablation of spontaneous ventilation: Due to the limited respiratory reserve in small pediatric patients, it is often safer to maintain spontaneous ventilation while attempting intubation

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Suggested Equipment for Pediatric Difficult Airway Cart
EquipmentSize
Oral and nasopharyngeal airwaysVarious sizes
ETTPediatric and adult
Laryngeal mask airwaySizes 1, 1.5, 2, 2.5, 3, 4, 5
Combitube (small adult size)
Fastrach LMASizes 3, 4, 5
Laryngoscope handlesShort and long handles
Laryngoscopy blades
  • Mac 0, 1, 2, 3, 4
  • Miller 0, 1, 2, 3, 4
  • Oxyscope (with port built-in for blow-by oxygen)
Batteries for handles
Magill forcepsPediatric and adult
IV catheters
Syringes
Intubation guides
  • Stylets
  • Tube exchangers
  • Elastic bougies
Tracheostomy kit
Percutaneous needle cricothyrotomy kit
Swivel adapters
No. 3 straight connectors
Suction catheters6, 8, 10, and 14 Fr
Yankauer suction tipPediatric and adult
Surgical lubricant
2% and 4% lidocaine for topicalization
Atomizer
Face masksSize 1, 2, 3, 4, 5
Ambu bagPediatric and adult
Advanced airway equipment
  • Flexible fiber-optic bronchoscope
  • Rigid bronchoscope
  • Retrograde intubation kit with guidewire
  • Lighted stylets
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1. Wheeler M, Cote CJ, Todres ID. The pediatric airway. In: Cote CJ, Lerman J, Todres ID, eds. A Practice of Anesthesia for Infants and Children. Philadelphia, PA: Saunders Elsevier; 2009:237–278.
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2. Wheeler M. Management strategies for the difficult pediatric airway. Anesthesiol Clin North America. 1998;16(4):743–761.
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3. Caplan RA, Benumof JL, Berry FA, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2003 May;98(5):1269–1277.   [PubMed: 1277151]

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