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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2019

Open Access 01-12-2019 | Laryngoscopy | Guideline

The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel

Authors: Wojciech Walas, Dawid Aleksandrowicz, Maria Kornacka, Tomasz Gaszyński, Ewa Helwich, Marek Migdał, Andrzej Piotrowski, Grażyna Siejka, Tomasz Szczapa, Alicja Bartkowska-Śniatkowska, Zenon P. Halaba

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2019

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Abstract

Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient’s death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.
Literature
1.
Sands SA, Edwards BA, Kelly VJ, Davidson MR, Wilkinson MH, Berger PJ. A model investigation of the impact of ventilation-perfusion mismatch on oxygenation during apnea in preterm infants. J Theor Biol. 2010;264:657–62.PubMedCrossRef
2.
Hardman JG, Wills JS. The development of hypoxaemia during apnoea in children: a computational modelling investigation. Br J Anaesth. 2006;97:564–70.CrossRefPubMed
3.
Heinrich S, Birkholz T, Ihmsen H, et al. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth. 2012;22(8):729–36.PubMedCrossRef
4.
Heinrich S, Birkholz T, Ihmsen H, et al. Incidence and predictors of poor laryngoscopic view in children undergoing pediatric cardiac surgery. J Cardiothorac Vasc Anesth. 2013;27(3):516–21.PubMedCrossRef
5.
Frerk C, Mitchell VS, McNarry AF, et al. I difficult Airway society intubation guidelines working group: difficult Airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–48.PubMedPubMedCentralCrossRef
6.
Myatra SN, Shah A, Kundra P, et al. All India difficult Airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth. 2016;60:885–98.PubMedPubMedCentralCrossRef
7.
Apfelbaum JL, Hagberg CA, Caplan RA, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult Airway. Anesthesiology. 2013;118:251–70.PubMedCrossRef
8.
Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth. 2013;60:1089–118.PubMedPubMedCentralCrossRef
9.
Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management - part 2 - the anticipated difficult airway. Can J Anaesth. 2013;60:1119–38.PubMedPubMedCentralCrossRef
10.
Chrimes N. The vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. Br J Anaesth. 2016;117(Suppl 1):i20–7.PubMedCrossRef
11.
Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA, Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015;25:346–62.CrossRefPubMed
12.
Pawar DK, Doctor JR, Raveendra US, et al. All India difficult Airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in Paediatrics. Indian J Anaesth. 2016;60:906–14.PubMedPubMedCentralCrossRef
13.
Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth. 2010;20:454–64.PubMedCrossRef
14.
Marraro G. Airway management. In: Bissonnette B, editor. Pediatric anesthesia. Shelton: PMPH-USA; 2011. p. 1167–85.
15.
Airway management and ventilation. In: Wyllie J ed. Newborn Life Support. Course Manual. ERC Guidelines 2015 Edition. European Resuscitation Council vzw, Emile Vanderveldelaan 35, 2845 Niel, Belgium. ISBN 9789079157846
16.
Lönnqvist P-A. Management of the Neonate: anesthetic considerations. In: Bissonnette B, editor. Pediatric anesthesia. Shelton: PMPH-USA; 2011. p. 1437–75.
17.
Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: the debate should finally end. Anesthesiology. 2013;118:500–1.PubMedCrossRef
18.
Shi F, Xiao Y, Xiong W, Zhou Q, Huang X. Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth. 2016;30:3–11.PubMedCrossRef
19.
20.
Thomas RE, Rao SC, Minutillo C, Hullett B, Bulsara MK. Cuffed endotracheal tubes in infants less than 3 kg: a retrospective cohort study. Paediatr Anaesth. 2018;28:204–9.PubMedCrossRef
21.
Chand R, Roy Chowdhury S, Rupert E, Mandal CK, Narayan P. Benefits of using high-volume–low-pressure tracheal tube in children undergoing congenital cardiac surgery: evidence from a prospective randomized study. Semin Cardiothorac Vasc Anesth. 2018;22:300–5.PubMedCrossRef
22.
Thomas R, Rao S, Minutillo C. Cuffed endotracheal tubes for neonates and young infants: a comprehensive review. Arch Dis Child Fetal Neonatal Ed. 2016;101:F168–74.PubMedCrossRef
23.
Weiss M, Dullenkopf A, Fisher IE, Keller C, Gerber AC. Prospective randomized controlled multi-Centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth. 2009;103:867–73.PubMedCrossRef
24.
Manowska M, Bartkowska-Śniatkowska A, Zielińska M, et al. The consensus statement of the Paediatric section of the polish Society of Anaesthesiology and Intensive Therapy on general anaesthesia in children under 3 years of age. Anaesthesiol Intensive Ther. 2013;45:119–33.PubMedCrossRef
25.
Veyckemans F. Anesthesia equipment. In: Bissonnette B, editor. Pediatric anesthesia. Shelton: PMPH-USA; 2011. p. 594–668.
26.
Moloney G. Which endotracheal tube in neonates, infants, and small children? In: Bissonnette B, editor. Pediatric anesthesia. Shelton: PMPH-USA; 2011. p. 745–52.
27.
Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997;86:627–31.PubMedCrossRef
28.
Deakers TW, Reynolds G, Stretton M, Newth CJ. Cuffed endotracheal tubes in pediatric intensive care. J Pediatr. 1994;125:57–62.PubMedCrossRef
29.
Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth. 1994;41:771–4.PubMedCrossRef
30.
Hardman JG, Willis JS. The development of hypoxaemia during apnoea in children: a computational modeling investigation. Br J Anaesth. 2006;97:564–70.CrossRefPubMed
31.
Hardman JG, Wills JS, Aitkenhead AR. Factors determining the onset and course of hypoxaemia during apnoea: an investigation using physiological modeling. Anesth Analg. 2000;90:619–24.PubMedCrossRef
32.
Farmery AD, Roe PG. A model to describe the rate of oxyhaemoglobin desaturation during apnoea. Br J Anaesth. 1996;76:284–91.PubMedCrossRef
33.
Morrison JE Jr, Collier E, Friesen RH, Logan L. Preoxygenation before laryngoscopy in children: how long is enough? Paediatr Anaesth. 1998;8:293–8.PubMedCrossRef
34.
Steiner JW, Sessler DI, Makarova N, et al. Use of deep laryngeal oxygen insufflation during laryngoscopy in children: a randomized clinical trial. Br J Anaesth. 2016;117:350–7.CrossRefPubMed
35.
Karsli C, Issac LA. Induction of anesthesia. In: Bissonnette B, editor. Pediatric anesthesia. Shelton: PMPH-USA; 2011. p. 669–89.
36.
Ikeda A, Isono S, Sato Y, et al. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway anatomy. Anesthesiology. 2012;117:487–93.PubMedCrossRef
37.
38.
Walker RW, Ellwood J. The management of difficult intubation in children. Paediatr Anaesth. 2009;19(Suppl 1):77–87.PubMedCrossRef
39.
Lerman J, Creighton RE. Two hands, three sites: show me the vocal cords. Paediatr Anaesth. 2006;16:96.PubMedCrossRef
40.
Kojima T, Laverriere EK, Owen EB, et al. Clinical impact of external laryngeal manipulation during laryngoscopy on tracheal intubation success in critically ill children. Pediatr Crit Care Med. 2018;19(2):106–14.PubMedCrossRef
41.
Bhende MS, Thompson AE, Cook DR, Saville AL. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann Emerg Med. 1992;21:142–5.PubMedCrossRef
42.
Chun R, Kirkpatrick AW, Sirois M, et al. Where's the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disaster Med. 2004;19:366–9.PubMedCrossRef
43.
Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology. 2012;102:185–9.PubMedCrossRef
44.
Sethi A, Nimbalkar A, Patel D, Kungwani A, Nimbalkar S. Point of care ultrasonography for position of tip of endotracheal tube in neonates. Indian Pediatr. 2014;51:119–21.CrossRefPubMed
45.
Jaeel P, Sheth M, Nguyen J. Ultrasonography for endotracheal tube position in infants and children. Eur J Pediatr. 2017;176:293–300.CrossRefPubMed
46.
Yates AP, Harries AJ, Hatch DJ. Estimation of nasotracheal tube length in infants and children. Br J Anaesth. 1987;59:524–6.PubMedCrossRef
47.
Lau N, Playfor SD, Rashid A, Dhanarass M. New formulae for predicting tracheal tube length. Paediatr Anaesth. 2006;16:1238–43.PubMedCrossRef
48.
Windpassinger M, Plattner O, Gemeiner J, et al. Pharyngeal oxygen insufflation during AirTraq laryngoscopy slows arterial desaturation in infants and small children. Anesth Analg. 2016;122:1153–7.PubMedCrossRef
49.
Lee JH, Turner DA, Kamat P, et al. The number of tracheal intubation attempts matter! A prospective multi-institutional pediatric observational study. BMC Pediatr. 2016;16:58.PubMedPubMedCentralCrossRef
50.
Wołoszczuk-Gębicka B, Zawadzka-Głos L, Lenarczyk J, Sitkowska BD, Rzewnicka I. Two cases of the “cannot ventilate, cannot intubate” scenario in children in view of recent recommendations. Anaesthesiol Intensive Ther. 2014;46:88–91.PubMedCrossRef
51.
Owada G, Mihara T, Inagawa G, Asakura A, Goto T, Ka K. A comparison of the Airtraq®, McGrath®, and Macintosh laryngoscopes for difficult paediatric intubation: a manikin study. PLoS One. 2017;12(2):e0171889.PubMedPubMedCentralCrossRef
52.
Dwivedi D, Bhatnagar V, Tandon U, Jinjil K. Pediatric difficult intubation in a rare genetic disorder made easy with Airtraq laryngoscope. Anesth Essays Res. 2016;10:684–5.PubMedPubMedCentralCrossRef
53.
Redel A, Karademir F, Schlitterlau A, et al. Validation of the GlideScope video laryngoscope in pediatric patients. Paediatr Anaesth. 2009;19:667–71.PubMedCrossRef
54.
Macnair D, Baraclough D, Wilson G, Bloch M, Engelhardt T. Pediatric airway management: comparing the Berci-Kaplan video laryngoscope with direct laryngoscopy. Paediatr Anaesth. 2009;19:577–80.PubMedCrossRef
55.
Vlatten A, Aucoin S, Litz S, Macmanus B, Soder C. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the pediatric airway – a randomized clinical trial. Paediatr Anaesth. 2009;19:1102–7.CrossRefPubMed
56.
Jansen AH, Johnston G. The Shikani optical stylet: a useful adjunct to airway management in a neonate with popliteal pterygium syndrome. Paediatr Anaesth. 2008;18:188–90.PubMedCrossRef
57.
Shukry M, Hanson RD, Koveleskie JR, Ramadhyani U. Management of the difficult pediatric airway with Shikani optical stylet. Paediatr Anaesth. 2005;15:342–5.PubMedCrossRef
58.
Xue FS, Luo MP, Liao X, Zhang YM. Trachlight guided airway topical anesthesia in children with difficult airways. Paediatr Anaesth. 2009;19:415–8.PubMedCrossRef
59.
Xue FS, Liu JH, Zhang YM, Liao X. The lightwand-guided digital intubation in newborns and infants with difficult airways. Paediatr Anaesth. 2009;19:702–4.PubMedCrossRef
60.
Vlatten A, Aucoin S, Litz S, MacManus B, Soder C. A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study. Paediatr Anaesth. 2010;20:559–65.PubMedCrossRef
61.
Fiadjoe JE, Hirschfeld M, Wu S, et al. A randomized multi-institutional crossover comparison of the GlideScope® cobalt video laryngoscope to the flexible fiberoptic bronchoscope in a Pierre Robin manikin. Paediatr Anaesth. 2015;25:801–6.PubMedCrossRef
62.
Liu GP, Li RP, Xue FS. Comparing intubation performance of Bonfils fiberscope and fiberoptic bronchoscope in difficult pediatric airways. Paediatr Anaesth. 2015;25:217.PubMedCrossRef
63.
Fiadjoe JE, Stricker P, Gurnaney H, et al. Ultrasound-guided tracheal intubation: a novel intubation technique. Anesthesiology. 2012;117:1389–91.PubMedCrossRef
64.
Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Paediatr Anaesth. 2012;22:1008–15.PubMedCrossRef
65.
Tong DS, Beus J, Liman RS. The Childrens’s Hospital of Philadelphia Difficult Intubation Registry. Anesthesiology. 2007;107:A1637.
66.
Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the fourth National Audit Project of the Royal College of Anaesthetists and the difficult Airway society. Part 1: anaesthesia. Br J Anaesth. 2011;106:617–31.PubMedCrossRef
67.
von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010;376:773–83.CrossRef
68.
Mamie C, Habre W, Delhumeau C, Argiroffo CB, Morabia A. Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth. 2004;14:218–24.PubMedCrossRef
69.
Kusumaphanyo C, Charuluxananan S, Sriramatr D, Pulnitiporn A, Sriraj W. The Thai anesthesia incident monitoring study (Thai AIMS) of anesthetic equipment failure/malfunction: an analysis of 1996 incident reports. J Med Assoc Thail. 2009;92:1442–9.
70.
Engelhardt T, Weiss M. A child with a difficult airway: what do I do next? Curr Opin Anaesthesiol. 2012;25:326–32.PubMedCrossRef
71.
Tracy MB, Klimek J, Coughtrey H, et al. Mask leak in one-person mask ventilation compared to two-person in newborn infant manikin study. Arch Dis Child Fetal Neonatal Ed. 2011;96:F195–200.PubMedCrossRef
72.
Parhizkar N, Saltzman B, Grote K, et al. Nasopharyngeal airway for management of airway obstruction in infants with micrognathia. Cleft Palate Craniofac J. 2011;48:478–82.PubMedCrossRef
73.
74.
Abel F, Bajaj Y, Wyatt M, Wallis C. The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience. Arch Dis Child. 2012;97:331–4.PubMedCrossRef
75.
Bradley AE, White MC, Engelhardt T, Bayley G, Beringer RM. Current UK practice of pediatric supraglottic airway devices - a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland. Paediatr Anaesth. 2013;23:1006–9.PubMedCrossRef
76.
Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013;84:722–30.PubMedCrossRef
77.
78.
79.
Reynolds PI, O'Kelly SW. Fiberoptic intubation and the laryngeal mask airway. Anesthesiology. 1993;79:1144.PubMedCrossRef
80.
Benumof JL. A new technique of fiberoptic intubation through a standard LMA. Anesthesiology. 2001;95:1541.PubMedCrossRef
81.
Weiss M, Schwarz U, Dillier C, Fischer J, Gerber AC. Use of the intubating laryngeal mask in children: an evaluation using video-endoscopic monitoring. Eur J Anaesthesiol. 2001;18:739–44.PubMedCrossRef
82.
Jöhr M, Berger TM. Fiberoptic intubation through the laryngeal mask airway (LMA) as a standardized procedure. Paediatr Anaesth. 2004;14:614.PubMedCrossRef
83.
Weiss M, Mauch J, Becke K, Schmidt J, Jöhr M. Fibre optic-assisted endotracheal intubation through the laryngeal mask in children. Anaesthesist. 2009;58:716–21.PubMedCrossRef
84.
Walker RW. The laryngeal mask airway in the difficult paediatric airway: an assessment of positioning and use in fibreoptic intubation. Paediatr Anaesth. 2000;10:53–8.CrossRefPubMed
85.
Zhi J, Deng XM, Yang D, et al. Comparison of the Ambu Aura-i with the air-Q intubating laryngeal Airway as a conduit for Fiberoptic-guided tracheal intubation in children with ear deformity. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2016;38:637–42.PubMed
86.
Thomas PB, Parry MG. The difficult paediatric airway: a new method of intubation using the laryngeal mask airway, Cook airway exchange catheter and tracheal intubation fibrescope. Paediatr Anaesth. 2001;11:618–21.PubMedCrossRef
87.
Selim M, Mowafi H, Al-Ghamdi A, Adu-Gyamfi Y. Intubation via LMA in pediatric patients with difficult airways. Can J Anaesth. 1999;46:891–3.PubMedCrossRef
88.
Newgard CD, Koprowicz K, Wang H, et al. Variation in the type, rate, and selection of patients for out-of-hospital airway procedures among injured children and adults. Acad Emerg Med. 2009;16:1269–76.PubMedPubMedCentralCrossRef
89.
Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatr Anaesth. 2009;19(Suppl 1):66–76.PubMedCrossRef
90.
Advanced Paediatric Life Support: A Practical Approach to Emergencies, 6th Edition. Chichester: Wiley. 2016. ISBN: 9781118947647.
91.
92.
Navsa N, Tossel G, Boon JM. Dimensions of the neonatal cricothyroid membrane - how feasible is a surgical cricothyroidotomy? Paediatr Anaesth. 2005;15:402–6.CrossRefPubMed
93.
Corbett HJ, Mann KS, Mitra I, Jesudason EC, Losty PD, Clarke RW. Tracheostomy – a 10-year experience from a UK pediatric surgical center. J Pediatr Surg. 2007;42:1251–4.PubMedCrossRef
94.
Chong CF, Wang TL, Chang H. Percutaneous transtracheal ventilation without a jet ventilator. Am J Emerg Med. 2003;21:507–8.PubMedCrossRef
95.
Zornow MH, Thomas TC, Scheller MS. The efficacy of three different methods of transtracheal ventilation. Can J Anaesth. 1989;36:624–8.PubMedCrossRef
96.
Steward DJ. Percutaneous transtracheal ventilation for laser endoscopic procedures in infants and small children. Can J Anaesth. 1987;34:429–30.PubMedCrossRef
97.
Li S, Liu Y, Tan F, Chen J, Chen L. Efficacy of manual jet ventilation using Manujet III for bronchoscopic airway foreign body removal in children. Int J Pediatr Otorhinolaryngol. 2010;74:1401–4.PubMedCrossRef
98.
Sanguanwit P, Trainarongsakul T, Kaewsawang N, Sawanyawisuth K, Sitthichanbuncha Y. Is retrograde intubation more successful than direct laryngoscopic technique in difficult endotracheal intubation ? Am J Emerg Med. 2016;34:2384–7.PubMedCrossRef
99.
Ciftci T, Erbatur S. Retrograde intubation via laryngeal mask airway in a paediatric patient with fallot-type ventricular septal defect and cleft palate deformity. Middle East J Anaesthesiol. 2016;23:479–82.PubMed
100.
Miner JR, Rubin J, Clark J, Reardon RF. Retrograde intubation with an Extraglottic device in place. J Emerg Med. 2015;49:864–7.PubMedCrossRef
101.
He M. Emergent retrograde tracheal intubation in a 3-year-old with stevens-johnsons syndrome. A A Case Rep. 2014;2:7–8.PubMedCrossRef
102.
Cui XL, Wang SY, Xue FS. Fiberoptic and retrograde intubation in difficult pediatric airway: useful suggestions. J Neurosurg Anesthesiol. 2014;26:257–8.PubMedCrossRef
103.
McLaughlin J, Iserson KV. Emergency pediatric tracheostomy: a usable technique and model for instruction. Ann Emerg Med. 1986;15:463–5.PubMedCrossRef
Metadata
Title
The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel
Authors
Wojciech Walas
Dawid Aleksandrowicz
Maria Kornacka
Tomasz Gaszyński
Ewa Helwich
Marek Migdał
Andrzej Piotrowski
Grażyna Siejka
Tomasz Szczapa
Alicja Bartkowska-Śniatkowska
Zenon P. Halaba
Publication date
01-12-2019
Publisher
BioMed Central
DOI
https://doi.org/10.1186/s13049-019-0666-7

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