The difficult pediatric airway
- Nathan W Mick, MD
Nathan W Mick, MD
- Associate Professor
- Tufts University School of Medical
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will review conditions in children that can make airway management difficult, anatomic characteristics that may identify those conditions, and management strategies.
General principles of airway management in children, including rapid sequence intubation are discussed separately. (See "Basic airway management in children" and "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children".)
Effective airway management includes anticipating and planning for problems. Difficulties frequently occur as the result of patient characteristics that interfere with spontaneous breathing, bag mask ventilation, laryngoscopy, and/or intubation of the trachea. Identifying characteristics of the difficult airway and developing a plan for managing problems are essential principles of anesthesia practice . These principles have been modified and effectively used to evaluate adults in the emergency department .
Children infrequently require aggressive airway management and difficulties do not occur often [3,4]. As a result, evidence specific for children regarding identification and management of difficult airways is limited [5,6]. Nevertheless, a reasonable, systematic approach for children can be developed from experience with adult patients in the operating room and emergency department.
A difficult airway is generally defined as a situation in which a clinician experiences difficulty with face mask ventilation, laryngoscopy, or intubation [1,2]. In an emergency setting, this also includes difficulty performing an emergency surgical airway, such as needle cricothyroidotomy.
- Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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.
- Murphy, MF, Walls, RM. Identification of the difficult and failed airway. In: Manual of emergency airway management, 2nd, Walls, RM (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.74.
- Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002; 18:417.
- Pallin DJ, Dwyer RC, Walls RM, et al. Techniques and Trends, Success Rates, and Adverse Events in Emergency Department Pediatric Intubations: A Report From the National Emergency Airway Registry. Ann Emerg Med 2016.
- Luten, RC, Kisson, N. The difficult pediatric airway. In: Manual of Emergency Airway Management, 2nd, Walls, RM, Murphy, MF, Luten, RC, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.236.
- Graciano AL, Tamburro R, Thompson AE, et al. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med 2014; 40:1659.
- Blank RS, de Souza DG. Anesthetic management of patients with an anterior mediastinal mass: continuing professional development. Can J Anaesth 2011; 58:853.
- DeBoer S, McNeil M, Amundson T. Tongues, tubes, and teens: body piercing and airway management. Pediatr Emerg Care 2006; 22:755.
- Nafiu OO, Burke CC, Gupta R, et al. Association of neck circumference with perioperative adverse respiratory events in children. Pediatrics 2011; 127:e1198.
- Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006; 105:885.
- Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 2005; 103:429.
- Naguib M, Scamman FL, O'Sullivan C, et al. Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study. Anesth Analg 2006; 102:818.
- Krobbuaban B, Diregpoke S, Kumkeaw S, Tanomsat M. The predictive value of the height ratio and thyromental distance: four predictive tests for difficult laryngoscopy. Anesth Analg 2005; 101:1542.
- Lee A, Fan LT, Gin T, et al. A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg 2006; 102:1867.
- Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005; 22:99.
- Dingeman RS, Goumnerova LC, Goobie SM. The use of a laryngeal mask airway for emergent airway management in a prone child. Anesth Analg 2005; 100:670.
- Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database Syst Rev 2005; :CD003314.
- King, C. Emergent endotracheal intubation. In: Textbook of Pediatric Emergency Procedures, Henretig, FM, King, C (Eds), Lippincott Williams & Wilkins, Philadelphia 1997. p.161.
- Fisher QA, Tunkel DE. Lightwand intubation of infants and children. J Clin Anesth 1997; 9:275.
- Fox DJ, Matson MD. Management of the difficult pediatric airway in an austere environment using the lightwand. J Clin Anesth 1990; 2:123.
- Berns SD, Patel RI, Chamberlain JM. Oral intubation using a lighted stylet vs direct laryngoscopy in older children with cervical immobilization. Acad Emerg Med 1996; 3:34.
- Walker RW. Management of the difficult airway in children. J R Soc Med 2001; 94:341.
- Mlinek EJ Jr, Clinton JE, Plummer D, Ruiz E. Fiberoptic intubation in the emergency department. Ann Emerg Med 1990; 19:359.
- Agrò F, Frass M, Benumof J, et al. The esophageal tracheal combitube as a non-invasive alternative to endotracheal intubation. A review. Minerva Anestesiol 2001; 67:863.
- Luten, RC, Godwin, SA. Pediatric airway techniques. In: Manual of Emergency Airway Management, 2nd, Walls, RM (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.228.
- Oczenski W, Krenn H, Dahaba AA, et al. Complications following the use of the Combitube, tracheal tube and laryngeal mask airway. Anaesthesia 1999; 54:1161.
- Vézina D, Lessard MR, Bussières J, et al. Complications associated with the use of the Esophageal-Tracheal Combitube. Can J Anaesth 1998; 45:76.
- Moser MS. Piriform sinus perforation during esophageal-tracheal combitube placement. J Emerg Med 1999; 17:129.
- McGlinch BP, Martin DP, Volcheck GW, Carmichael SW. Tongue engorgement with prolonged use of the esophageal-tracheal Combitube. Ann Emerg Med 2004; 44:320.
- Keller C, Brimacombe J, Boehler M, et al. The influence of cuff volume and anatomic location on pharyngeal, esophageal, and tracheal mucosal pressures with the esophageal tracheal combitube. Anesthesiology 2002; 96:1074.
- Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000; 283:783.
- Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 2004; 56:531.
- Glicklich M, Cohen RD, Jona JZ. Steroids and bag and mask ventilation in the treatment of acute epiglottitis. J Pediatr Surg 1979; 14:247.
- Murphy, MF. Sedation and anesthesia for awake intubation. In: Manual of Emergency Airway Management, 2nd, Walls, RM (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.82.
- CAUSES OF THE DIFFICULT PEDIATRIC AIRWAY
- Normal pediatric airway
- Congenital abnormalities
- Acquired conditions
- - Infection
- - Anaphylaxis
- - Trauma
- - Foreign body
- - Other causes
- IDENTIFICATION OF THE DIFFICULT PEDIATRIC AIRWAY
- Bag mask ventilation
- Laryngoscopy or intubation
- The LEMON approach to difficult airway assessment
- ALTERNATIVE AIRWAY TECHNIQUES
- Laryngeal mask airway
- Intubating introducers (gum elastic bougie)
- Lighted stylet
- Fiberoptic stylets
- Flexible fiberoptic intubation
- Video laryngoscopy
- Surgical airway
- Supportive care
- Airway management
- - Crash airway
- - Rapid sequence intubation
- - Awake intubation
- - Alternative airway techniques
- Forced to act scenario
- Approach to the failed airway
- SUMMARY AND RECOMMENDATIONS