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Indian J.

PG
300 ISSUE2005;
Anaesth. : AIRWAY
49 (4) : MANAGEMENT
300 - 307 INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
300

AIRWAY MANAGEMENT IN CHILDREN


Dr. Pankaj Kundra1 Dr. Hari Krishnan S.2

Introduction more cephalic position C3 – C4 at birth, C4 – C5 at 2 years


Paediatric airway management remains the most of age, C5 – C6 by adulthood (fig. 1). A cephalic and
daunting task before the anaesthesiologist. However, the superior position on larynx in infants creates more acute
laryngeal structures are so soft and pliable that external angulations between glottis and base of tongue hence
laryngeal manipulation of the airway makes the task much posterior displacement is often necessary to improve the
easier than expected. Often in the absence of a fibreoptic view. Larynx is funnel shaped (cylindrical in adults) till
scope unconventional or alternative methods are used to 6–8 years of age because cricoids cartilage (glottis in adults)
secure the airway with success. Success of any such is the narrowest part of airway. The vocal cords are bow
technique depends upon constant maintenance of an shaped making an angle with anterior commissure, where
unobstructed airway and sufficient satisfactory depth of as the plane of vocal cords is perpendicular to long axis of
anaesthesia during the airway manipulation.1 trachea and vocal cords are linear in adults (fig. 1). This
angulations of vocal cords increase the chance of endotracheal
Difference between adult and paediatric airway tube (ETT) abutting the anterior commissure during blind
Understanding the anatomical and physiological intubation.
features of paediatric airway facilitates the development of
a rational set of strategies to manage normal and difficult
paediatric airway patients. When the differences are
understood it will be clear that paediatric airway is a
different airway and not a difficult airway.
Infants have small nares and nasal passages. In infants
head is large compared to body size resulting in automatic
sniffing position without elevation of occiput. Infants have
a large tongue in relation to oral cavity. Base of tongue is
situated in close proximity to laryngeal inlet. This caudal Fig. 1 : Schematic diagram showing the difference between adult and
insertion is called glossoptosis. Tonsils are small in newborn paediatric airway.
but it grows to maximal size at 4 – 7 years of age. Enlarged
tonsils may obscure laryngeal view or may interfere with Trachea in infants is short narrow and angled
mask ventilation. In infants epiglottis lies at the level of C1 posteriorly resulting in accidental endobronchial intubation
(adults C3) touching the soft palate separating oesophageal or extubation with changes in head position. Ribs are
inlet from laryngeal inlet2 hence infants are obligate nose horizontal with decreased anterior posterior and cephalic
breathers till 2 – 6 months of age, the ability to breath movements; hence the diaphragm is the mainstay of
orally is age related and increases with postnatal age.3 The ventilation in neonates. The angle formed by abdominal
epiglottis in infants is large stiff and omega shaped compared wall and diaphragm is more acute in infants, which reduces
to short broad and flat epiglottis of adults (fig. 1). Epiglottis the mechanical efficiency during contraction. In addition
sits at 45o angles to anterior pharyngeal wall (adults 20o), infants have higher percentage of type II fibres4 (fast
as a result of which epiglottis should be picked up with the twitch low oxidative) in their respiratory musculature leading
blade for better visualization of glottis. Larynx lies in a to early appearance of respiratory fatigue.

1. M.D.,MAMS, FIMSA, Prof. Congenital airway anomalies and airway management


2. M.B.B.S., Junior Resident in these children
Dept. of Anaesthesiology and Critical Care Paediatric airway may be complicated by a number
Jawaharlal Institute of Postgraduate Medical Education
and Research, Pondicherry 605006
of syndromes involving head neck and cervical spine. These
Correspond to : syndromes may result in difficulty in establishing or
Dr. Pankaj Kundra maintaining gas exchange via a mask, an artificial airway
D – II/21, JIPMER Campus. Pondicherry 605006, India or both (table 1).
E- mail : pankajkundra@vsnl.net, p_kundra@hotmail.com
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 301

Table - 1 : Congenital syndromes associated with Table - 2 : Agents used for sedation
difficult airway.
Drugs Advantages Disadvantages
Anatomical Location Syndrome Anomaly Midazolam Amnesia, reversible Airway reflexes not blunted
Head Hydrocephalus Macrocephaly Opioids Reversible Risk of apnoea
Mandible Pierre Robin Sequence Micrognathia & Ketamine Adequate spontaneous Post anaesthetic delerium,
and Treacher Collin’s Mandibular Hypoplasia ventilation. Prevents Sympathetic stimulation.
Syndrome airway reflexes during Increased airway secretions.
airway manipulation No reversal agent
Mid Facial Apert’s Syndrome Maxillary Hypoplasia

Temporomandibular Joint Arhrogryposis Ankylosis The advantages of awake intubation are preserving
Cocayane Syndrome
of normal airway tone and respiratory efforts. The
Mouth and Tongue Down’s Syndrome Macroglossia
disadvantages are a struggling child, increased haemodynamic
Mucopolysaccharadosis Macroglossia responses and the risk of raise in intracranial pressure.7
Freeman Sheldon We suggest a plan for airway management in anticipated
Syndrome Microstomia difficult airway.
Neurofibromatosis Masses obstructing
airway Inhalational Induction
In child with difficult but “uncompromised airway”
Struge Weber Masses obstructing
Syndrome airway inhalation induction is by far the preferred choice. The
success of inhalation induction will depend upon the
Dental Cocayane Syndrome Protruding Incisors
maintenance of airway patency throughout induction and
Cervical Spine Klippel- Fiel Syndrome Limited Mobility
ensuring adequate depth of anaesthesia before airway
Down’s Syndrome Instability manipulation. Halothane is the agent of choice. Sevoflurane
can also be used but because of its low solubility the depth
Airway assessment of anaesthesia rapidly diminishes during laryngoscopy.8
Prediction of difficult airway by the Samsoon and However, rapid recovery is one of the features that can be
Young modification of Mallampati classification in 476 of immense advantage in a child who develops airway
children between 0 (new born) to 16 years of age suggested obstruction following induction. The choice of an inhalational
an inaccurate prediction of a poor view during direct agent becomes irrelevant if a smaller size endotracheal
laryngoscopy. The assessment is often hampered by lack of tube is used as a nasopharyngeal airway in maintaining a
co-operation in infants and young children.5 No control patent upper airway and serve as a conduit to deliver
trials are yet available for evaluation of mandibular space, uninterrupted anaesthetic agent.1,9 In the meanwhile, the
neck mobility and jaw movements to predict difficult mouth or the other nostril can be used for securing the
laryngoscopy in paediatric population. Thus measurement airway.1 This facilitates control of the anaesthetic depth
of mentohyoid, thyromental, mandibular and inter dental necessary for airway manipulation. The same endotracheal
lengths have no value to predict difficult airway in tube can be advanced into the glottis. The depth of
paediatric patients. anaesthesia can be maintained if inspired agent
concentration is sufficient to offset the dilutional effects of
History of snoring,6 apnoea, daytime somnolence and room air. The advantage of this technique is that spontaneous
stridor may be indicative of airway obstruction, which may ventilation is preserved during airway instrumentation.
be exaggerated after induction. Physical examination should
include evaluation of the size and shape of head, gross Intravenous induction
facial features, size and symmetry of mandible, size of Targeting an adequate plane of anaesthesia without
tongue, prominence of upper incisors and range of motion compromising spontaneous ventilation is difficult with
in jaw, head and neck. intravenous induction agents. Propofol provides rapid
awakening and blunts airway reactivity. It is a good drug
Anaesthetic techniques
that permits a quick assessment of the laryngoscopic airway
In patients with difficult airway an awake intubation
grade. In addition a better control of the airway can be
is often the primary approach of airway management under
achieved with laryngeal mask airway (LMA) insertion under
sedation and adequate application of local anaesthetics to
propofol. The main disadvantage is the risk of apnoea,
the airway. Various agents have been used for sedation. It
which warrants extremely careful titration of an effective
is important to preserve spontaneous ventilation during
dose.
sedation (table 2).
302 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

Table - 3
Patient weight 4% Lignocaine (ml) Normal saline (ml)

10 – 14.9 0.5 0.5

15 – 19.9 1.0 1.0

20 – 24.9 1.5 0.5

25 – 29.9 2.0

30 – 34.9 2.5

35 – 39.9 3.0
Fig. 2 : Different blades used for laryngoscopy in children
A - Magill’s blade B - Macintosh blade
C - Bizzari-guffirda blade D - Wisconsin blade Rigid laryngoscopy
The keys for success with conventional rigid
Topical anaesthesia laryngoscopy includes age appropriate positioning, proper
Topical anaesthesia of airway improves child’s equipment selection, meticulous technique, minimal
acceptance of an airway device and blocks airway reflexes. number of attempts and optimal external laryngeal
It can be used in conjunction with either inhalational or manipulation (OELM)
intravenous induction once sufficient anaesthetic depth is Ideal position for infants and children under 2 years
reached for the child to tolerate laryngeal stimulus. of age is slight head extension without elevation of head
Lignocaine 10% spray is highly effective and care should with a roll under shoulders.10 A roll under the shoulders
be taken not to exceed the toxic dose limit. Except for helps to keep both the head and the shoulders lie in the
translaryngeal block all techniques used in adults can be same horizontal line. OELM is particularly useful for
used in children. Nebulized lignocaine is particularly useful children with limited mobility of cervical vertebrae and in
and can be used preoperatively or during induction with an infants.
inline attachment for nebulization to the anaesthetic circuit
(table 3).

Optimize child with premedication

Inhalational Induction

Assess airway patency on spontaneous ventilation


(Airway obstruction despite oropharyngeal airway?)

No airway obstruction Airway obstructi Fig. 3 : Laryngoscope blades

Maintain anaesthesia Use LMA

Intubation
Obstruction Obstruction Choosing laryngoscopes
persists relieved
Success Failure In general straight blade laryngoscopes are easier to
Awaken Type of surgery
use in infants and small children because of better alignment
of airway axis and reduced need for displacement of soft
Intubation Choices Aspiration Aspiration
likely unlikely tissue structures. Depending on the clinical situation certain
Non Surgical Surgical LMA as conduit Continue LMA
modified blades may be more effective for glottis
visualization (table 4).
1. Direct Laryngoscopy 1. PNC & TTJV* 1. Blind intubation
η Special Blades 2. PDC** 2. Fibreoptic assisted
η Retromolar approach 3. Tracheostomy 3. Guide wire assisted Retromolar approach
2. Flexible Fibreoptic Scope 4. Fibrescope and Guide wire
o
3. 70 Rigid Nasendoscope If difficulty is due to small mandible or a large
3. Blind Techniques
tongue this approach helps. The blade is introduced from
η Tactile the extreme right corner between the tongue and lateral
η Light wand
η Retrograde pharyngeal wall. The blade is advanced while staying to the
4. Combined Technique
η Retrograde wire and fibreoptic
right overlying the molars, until epiglottis or glottis is
* PNC & TTJV = Percutaneous needle cricothyrotomy and transtracheal jet ventilation seen. The proximal end of the blade is then brought to the
** PDC = Percutaneous dilational cricothyrotomy
midline. If glottis is not visualized the head can be turned
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 303

to the left to improve visualization. The higher rate of LMA is available in five sizes for use in paediatric
success is due to bypassing of tongue, incisors and maxillary patients. An LMA that is too large will be difficult do
structures.11 place. An LMA that is too small will not form a tight seal
and may be difficult to use if positive pressure ventilation
Table - 4 is required. Numerous methods are described for placing
the LMA in infants and children. The overall success rate
Clinical situation Modifications Examples of insertion during first attempt ranges from 67–90%.
Limited mouth Reduced step height and area Miller blade Dubreil et al17 showed the first attempt success rate of
opening of flange (fig. 3) LMA size 1 is 67% and size 2 to be 78%, however when
mean attempts and complication rate are compared there
Reduced mandibular Wide blade effectively Bizzari-Guffirda
space compresses tongue in blade (fig. 2C) was no significant difference. O’neil et al18 found partially
mandibular space inflating the cuff resulted in higher success rate and a
Macroglossia Sides of tongue hindering vision, Wisconsin blade
shorter time of insertion. LMA can be placed while it is
blades with adequate cross (fig. 2D, 3) rotated 90o in the lateral oropharynx to bypass base of the
sectional area with a slight Magill’s blade tongue and then rotated to 90o back to its correct placement.
opening in vertical plane/tubular (fig. 2A)
in cross section helps
Guedel’s method involved turning back the LMA with mask
opening facing the palate once the base of tongue it bypassed
Anterior larynx Blade with more pronounced Fink’s blade it is rotated to 180o. Kundra et al,19 described a partially
terminal curve enables the Philip’s blade
hyoid cartilage to be reached
deflated lateral insertion technique with a better 1st attempt
via the vallecula effectively success rate than the classical technique described by Brain.
pushing it forward The technique describes a partially inflated cuff by the
lateral approach that is relatively free of mechanical
Blind nasal intubation hindrance and allows a free passage as used for insertion
A well lubricated softened endotracheal tube (ETT) of the laryngoscope blade.
is introduced into a naris. The left naris is preferred as
The flexible reinforced LMA (RLMA) resists thinking
the leading edge stays in midline in hypopharynx, if right
and can be positioned to minimize interference with surgical
naris is used the leading edge frequently hitches the right
procedures involving lead in neck. It is available in sizes
vallecula. The ETT is directed into glottis by hearing for
2–5. It is slightly difficult to insert compared to classical
breath sound, or by capnograph trace. Successful placement
LMA. It is particularly useful in children with difficult
often will need manipulation of ETT, patients head and the
airway undergoing Head and neck surgeries.
larynx. A stylet with 30o angle can be placed into ETT
after it is placed in nasopharynx.12 Posterior manipulation LMA proseal specially designed for children (size
of stylet will displace the distal end of ETT anteriorly and 1.5–2.5) is now available. One of its main features is the
into the glottis. Elective blind nasotracheal intubation in lack of rear cuff. In children there is no difference in ease
prone position for a neonate with Pierre-Robin sequence of insertion and seal pressure between proseal and classical
has also been described.13 Higher failure rates are found in LMA.20 In contrast to adult studies, greater sealing pressure
patients with mid facial hypoplasia. and lower success rate of insertion in proseal LMA was not
observed in children. Proseal LMA offers no great advantage
Laryngeal mask airway against aspiration in children but the provision of drain tube
LMA has revolutionized difficult airway management may help to empty air insufflated stomach in paediatric
in children. LMA has been successfully used in paediatric patients with difficult mask ventilation.
patients in whom ventilation or intubation are extremely
LMA has been used a conduit for in intubation.21-23
difficult or impossible. LMA has been used.
Intubation through LMA can be blind, fibreoptic assisted,
• In recognized difficult airway for awake tracheal light wand assisted or retrograde assisted. Blind techniques
intubation.14 has variable success rate. Rowbothom et al24 evaluated the
• In difficult intubation when mask ventilation is adequate, position of LMA (size 1 – 3) in 100 patients. 98% of cases
LMA is used as a definitive airway or as a conduit had a patent airway but LMA was in perfect position in
for intubation.15 49% of patients, further in 15% of patients impingement of
epiglottis into aperture bars was noted hence the safest
• When both mask ventilation and intubation becomes approach to place ETT through LMA is through fibreoptic
difficult, LMA can be used as ventilation device.16 scope. Kundra et al19 demonstrated that there occurs a
304 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

direct correlation with the fibreoptic view grading of the


glottis through the LMA and subtle airway obstruction. A
higher grade was associated with a gradual rise in end tidal
carbon dioxide in spontaneously breathing children though
the oxygen saturation remains within normal limits in short
surgical procedures lasting around half an hour. Blind
insertion of ETT through an improperly positioned LMA Fig. 4 : Differences in the field of
will lead to airway trauma. vision between a zero degree endoscope
and a 70-degree endoscope
LMA classic
Mask size Patients size Maximum cuff Largest is made with 20/22 g intravenous cannula. After confirmation
volume ETT (ID) of correct position 0.018 / 0.025 inch wire can be threaded
1 Neonates up to 5 kg 4 3.5 in cephalic direction. In patients with limited mouth opening
these wires can be retrieved using suction catheters.26
1½ Infant 5 – 10 kg 7 4.0
Subsequent tracheal intubation may be performed directly
2 Children 10 – 20 kg 10 4.5 over a wire or the guide wire may be used as a stylet,
passed through the suction port of larger fibreoptic
2.5 Children 20 – 30 kg 14 5.0
bronchoscope. The preferred approach is a fibreoptic with
3 Children > 30 kg 20 6.0 retrograde wire the advantages being.

Rigid nasendoscopic intubation - Higher success rate


Conventional laryngoscopy causes distortion of the - Faster intubation
supraglottic structures and creates difficult conditions for - Ability to insufflate oxygen through the suction port
the glottis to be seen. If the airway anatomy is not distorted, - No hanging up of ETT in glottis
glottis might be viewed with greater ease by an endoscope. - No need to rely or anatomic landmarks.
The 70 degree lateral illumination of the rigid endoscope
provides an excellent view of the larynx as soon as the
endoscope is passed till the uvula under direct vision
(fig. 4). Its oral introduction is atraumatic and does not
require additional skills for viewing the larynx. The field
of vision has suitable magnification with superior resolution
as compared to the frontal/end-on vision of the flexible
fibrescope.25 Separately introducing the endotracheal tube
and the endoscope permits the use of an endotracheal tube
of an appropriate size to be inserted into the glottis. The
dynamics of endotracheal tube insertion can be viewed
continuously on the screen till the whole process is
completed. In the event of the endotracheal tube slipping
or being caught at the glottis, it can be manipulated
under visual control to negotiate the glottic aperture
Fig. 5 : Endoscopic views with the rigid nasendoscope used
(fig. 5). Nevertheless, the technique requires co-ordination for tracheal intubation.
between both hands (one hand holds the endoscope and 1. View of the glottis from a distance 2. Closer view of the glottis
fixes the view of the glottis and the other manipulates 3. View of glottis and tube together 4. Lifting the epiglottis with the tube
the endotracheal tube) and one assistant, to stabilize the 5. Manipulation of the tube into glottis 6. Final position of the tube
head and pull the tongue out and to monitor the child as the
endoscopist has to constantly focus his attention on the Tactile technique
monitor screen.21 Nasal or oral intubation can be accomplished using
this technique. It depends upon palpating epiglottis by
Retrograde intubation second and third fingers inserted through child’s mouth.
This method has been used in anticipated or Once epiglottis is palpated the tube can be guided into the
unanticipated difficult airway after convention intubation glottis by the fingers.
strategies failed. In children cricothyroid membrane puncture
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 305

Light wand Major limitation of TTJV is the need to maintain


Light wand can be used for orotracheal or patent airway cephalic to the catheter. If upper airway is
nasotracheal intubation. Transillumination is used as a obstructed life threatening barotraumas occurs.
guide for intubation. Tracheal placement results in well-
Cricothrotomy
circumscribed bright glow where as oesophageal placement
results in diffuse glow. It is particularly useful in children It is procedure of choice for emergency access of
with limited movement of cervical spine and in patients airway in all patients regardless of age, when conventional
with limited mouth opening. With light wand for successful means of airway control fails.30 In infants and in small
intubation there is no need for alignment of oral pharyngeal children the soft cartilages, ill defined cricothyroid
laryngeal axis. Ease of use is not related to difficulty in membrane makes this technique difficult.
direct laryngoscopy or Mallampattii score. Patient is positioned with optimal neck extension
The basic construction of a light wand is a light with rolls under the shoulders, so that larynx comes
source at the end of a malleable stylet connected to power anteriorly. Cricothyriod membrane is identified. A horizontal
source in handle.27 Light wands available for children include. incision is made over the skin overlying to membrane with
11 size blade. Incision is deepened and the membrane is
• Trach light – Accommodates ETT down to 2.5 mm
punctured with tip of the blade pointing caudally to avoid
• Anaesthesia medical specialties – Accommodates ETT injury to the oesophagus and vocal cards. Using a curved
down to 3.5 mm haemostat pointing caudally the entry point is widened and
• Aaron medical–Accommodates ETT down to 4.5 mm ETT or tracheostomy tube is inserted into the trachea.
A preselected tube of appropriate size is loaded Percutaneous dilatational cricocthyrotomy (PDC) is
onto a lubricated light wand stylet. It is then bent to the a variation of this technique, which uses Seldinger method
shape of hockey stick with head in neutral position. Light for insertion. Various kits are available (e.g. Pedia trake).
wand is introduced in the midline, guided by transillumination Only limited data are available of their use in paediatric
the light wand is advanced in midline till a well- age group hence PDC is not recommended for paediatric
circumscribed glow appears below the level of thyroid patients. Complications include bleeding, barotraumas and
prominence. The key for successful placement is to stay in oesophageal perforation.
midline and anteriorly.28 Once the light wand is in trachea
ETT is advanced off the light wand by railroad technique Postoperative airway problems in children
and light wand removed carefully. Most commonly occurring post operative airway
problems in children include
Complications of light wand include pharyngeal
trauma, arytenoid dislocation. The anatomic features that 1. Inability to tolerate extubation.
make light wand intubation difficult include short thick 2. Laryngospasm.
neck, large tongue and long floppy epiglottis. 3. Post intubation croup.
Transtracheal jet ventilation (TTJV) Other airways problems related to intubation are
TTJV is the percutaneous insertion of a catheter into mucosal lacerations in airway, arytenoids dislocation,
the trachea through cricothyrorid membrane and ventilation dental, temporomandibular joint trauma. They are rare with
is achieved using jet ventilation. The source gas pressure properly performed laryngoscopy and intubation.
used for jet ventilation in adults is 50 psi and in children
Inability to tolerate extubation
it is 30 psi.29
Inability to tolerate extubation may occur
TTJV is employed as an emergency airway. In commonly due to airway obstruction or due to hypoventilation
infants and children less than 5 yrs of age it has not syndromes. It should be borne in mind that extubation has
been recommended because of high incidence of vasovagal a potential of leading to a reintubation. Reintubation may
events, subcutaneous emphysema, bilateral pneumothorax, become a problem in children in whom securing the airway
inadvertent placement into oesophagus and submucosal false had been difficult or would now be difficult due to limited
passage in trachea. access following surgery. For such children it is wise to
In infants and children cricoid and thyroid carriages have a strategy that permits continued administration of
are soft and cricothyroid membrane is poorly defined. oxygen or provision for ventilation. This is achieved by use
Successful placement of catheter into infant trachea is also of reintubation guides or tube exchangers. Catheters used
more difficult to confirm. as reintubation guides in paediatric practice include Cooks
306 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

airway exchange catheter, Sheridan tracheal tube exchanger they may be prone to hypoventilation or respiratory
and Cardiomed endotracheal ventilation catheter, the outer obstruction.
diameters of which range from 2.0 – 5.8mm.
Management
The identification of patients with a high risk for Incomplete obstruction is associated with audible
post extubation complications is largely anecdotal. Children inspiratory or expiratory sound, if obstruction progresses
undergoing laryngoscopy, uvulopalato-pharyngoplasty, tracheal tug, paradoxical respiratory movements of chest
thyroid surgery, maxillofacial surgeries are more prone. and abdomen develop. Once complete obstruction develops
Extubation in fully awake condition and/or with reintubation audible sounds cease. One must remember that the primary
guides in situ avoids most of the catastrophic airway concern during laryngospasm is oxygenation of the patient
complications in the early postoperative period. and not intubation. Several therapeutic manoeuvres have
been suggested.
Laryngospasm
1. Removal the irritant stimuli like debris from larynx.
The incidence of perioperative laryngospasm is about
18/1000 patients in the age group of 0–9 years of age.31 2. Forward jaw thrust at the temporomandibular joint by
Infant’s 1–3 mo of age have highest incidence. The factors applying pressure on the ascending rami of mandible.
associated with increased risk of laryngospasm are presence This manoeuvre lengthens the thyrohyoid muscle and
of nasogastric tube, oral endoscopy surgeries, during unfolds the soft supraglottic tissue.
extubation. Inadequate anaesthetic depth is an important 3. Facilitate ventilation by applying gentle continuous
factor contributing to laryngospasm during extubation done positive airway pressure with 100% oxygen by a tight
in lighter planes. Laryngospasm occurs in response to glottis feeling face mask.
or supraglottic mucosal stimulation involving apposition of
Any measure of laryngoscopy and intubation attempt
structures at three levels
may turn incomplete obstruction to complete one. If these
1. Supraglottic folds. methods do not help and if the child remains hypoxic Succinyl
2. False vocal cords. choline 0.5 mgkg-1 relieves laryngospasm. In the event of
3. True vocal cords. bradycardia, atropine should be administered concomitantly
ensuring adequate oxygenation with 100% oxygen through a
Fink32 proposed a dual mechanism for closure of tight fitting face mask.
larynx. Firstly, a shutter effect can be seen due to the
closure of the vocal cords, which in turn leads to increase Post intubation croup
in translayrngeal pressure gradient. The soft tissues of the It is caused by inflammation of subglottic region due
supraglottic region become rounded and redundant due to to mechanical irritation of ETT. Contribution factors are
the shortening of thyrohyoid muscle, drawn into the laryngeal age (1–4 years), trauma during intubation, a tight fitting
inlet (Ball valve effect). Stridor gets manifested due to ETT with no leak at 25 – 40 cm H2O, surgery in neck
intermittent closure of glottis. region, children with previous history of croup and long
duration of intubation (more than 1 hour).
Prevention
Prevention is the ideal remedy. Patients with known Table - 5 : Downes scoring system
risk factors may be given intravenous lignocaine 2 mgkg-1
given slowly over a period of 30 sec, one min before 0 1 2
extubation. To derive any benefit from lignocaine Stridor None Inspiration Inspiration & expiration
administration, extubation should be done before signs of
swallowing activity appear.33 Another preventive measure Cough None Hoarse cry Bark

proposed is application of local anaesthetic agents to the Retraction & None Flaring & suprasternal Flaring, suprasternal,
supraglottic mucosa. Lee and Downes34 suggested. “The nasal flaring retraction subcostal, intercostal
retractions.
infant or child before tracheal extubation should open his
eyes or mouth spontaneously, move all extremities vigorously Cyanosis None On air On 40% oxygen
and resume a normal breathing pattern after a cough.” to
Inspiratory Normal Harsh with rhonchi Delayed
prevent laryngospasm. Extubation under surgical depth of breath sound
anaesthesia is advocated by some; however, no data are
available to support this view. This practice may lead to Clinical features : Stridor occurs soon after
premature transfer of children to the recovery room where extubation (within 1 hr). Maximum intensity is within 4 h
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 307

and complete resolution occurs within 24 hr. In severe 15. Selim M, Mowafi H, AlGhamdi A et al. Intubation via LMA in pediatric
patients with difficult airways. Can J Anaesth1999; 46: 891-93.
forms, subglottic oedema appears as a “steeple sign” in
16. Denny M, Desilva KA, Webber PA. Laryngeal mask airway for emergency
chest radiograph. A scoring system for post extubation croup tracheostomy, in a neonate. Anaesthesia 1990; 45: 895.
is described by Downes and Raphaely35 used for classifying 17. Dubreil M, Laffon M Plaud B et al. Complications and fibreoptic
croup into mild, moderate and severe (table 5). Normal assessment of size one laryngeal mask airway. Anesth Analg 1993; 76:
score is 0 and the maximum score is 10, patient with a 527-29.
score of 7 or more suggests prophylactic artificial ventilation 18. O’Neil B, Templeton JJ. Caramico L, et al. The laryngeal mask airway
in pediatric patients: Factors affecting ease of use during insertion and
(table 5). emergence. Anesth Analg 1994; 78: 659-62.
19. Kundra P, R. Deepak and M. Ravishankar. Technique of laryngeal mask
Treatment
airway insertion in children: A rational approach. Paed Anaesth. 2003;
1. Mild: Humidification, oxygen inhalation, hydration 13(8): 685-90.
20. Shimbhori H, Ono K, Miwa T et al. Comparison of LMA. ProsealTM
2. Moderate: Add epinephrine nebulization36 (0.25-0.5 ml and LMA classicTM in children. Br J Anaesth 2004; 93: 528-31.
racemic epinephrine in 2.5 ml normal saline) 21. Hansen J, Joenson H, Hennebeig SW et al. Laryngeal mask airway
guided intubation in a neonate with Pierre Robin Syndrome. Acta
3. Severe: Repeat epinephrine nebulization up to three Anaesthesiol Scand 1995; 30: 129.
times. If score > 7, consider artificial ventilation 22. Heard CM, Caldicott, Fletcher JE et al. Fibreoptic guided tracheal
intubation via the Laryngeal Mask Airway in a pediatric patient. A report
References of series of cases Anesth Analg 1996; 82:1287.
1. Kundra P, A Vasudevan, M Ravishankar. Video assisted fibreoptic intubation 23. Takafumi I, Kumikof F, Kazaya T et al. Orotracheal intubation through
for temporomandibular ankylosis. Ped Anesth 2005. Accepted for the laryngeal mask airway in paediatric patients with Treacher Collins
publication (4.6.2005). Syndrome. Paed Anaesth 1995; 5: 129.
2. Eckenhoff JE. Some anatomic considerations of infants influencing 24. Rowbothom SJ, Simpson DL, Grubb D. The laryngeal mask airway in
endotracheal anesthesia. Anesthesiology 1951; 12: 401. children. A fibreoptic assessment of positioning. Anaesthesia 1991; 46:
3. Miller MJ, Carlo WA, Strohl KP. Effect of maturation on oral breathing 489-91.
in sleeping premature infants. J Pediatr 1986; 109: 515-19. 25. Ravishankar M, Kundra P, Agrawal K et al. Rigid nasendoscope with
4. Keens TG, Lanuzzo CD. Development of fatigue resistant muscle fibres video camera system for intubation in infants with Pierre-Robin sequence.
in human ventilatory muscles. Am Rev Respir Dis 1979; 2: 139-41. Br J Anaesth 2002; 88: 728-31.
5. Koop VJ, Baily A, Vally RD et al. Utility of Mallampati classification 26. Bhattacharya P, Biswas BK, Bainwal.S. Retrieval of catheter using
for predicting difficult intubation in pediatric patients. Anesthesiology suction in patients who cannot open their mouths, Br J Anaesth 2004;
1995; 83A: 1146. 92: 888-90.
6. Hiremath AS, Hilman DR, Platt PR et al. Relationship between difficult 27. Agro F, Hung OR, Cataldo R et al. Light wand intubation using
tracheal intubation and obstructive sleep apnoea, Br J Anaesth 1998; 80: Trachlight: A brief review of current knowledge. Can J Anaesth 2001;
606-11. 48: 592-99.
7. Miller C, Bissonnete B. Awake tracheal intubation increases intracranial 28. Fisher QA, Tunkel DF. Light wand intubation in infants, children. J
pressure without affecting cerebral blood flow in infants. Can J Anesth Clin Anesth 1997; 275-79.
1994; 41: 281-87. 29. Depierraz B, Ravussin P, Brossard E, et al. Percutaneous transtracheal
8. Kerman J, Sikich N, Kleiman S et al. The pharmacology of sevoflurane jet ventilation for paediatric endoscopic laser treatment of laryngeal and
in infants and children. Anesthesiology 1994; 80: 814-24. subglottic lesions. Can J Anaesth 1994; 41: 1200-07.
9. Didem D. Airway management in a high risk infant with multiple 30. Tobais JD. Airway management for paediatric emergencies. Pediatr Ann
congenital anomalies and difficult airway. Acta Anaesthesiol Scand 2004; 1996; 25: 317-20.
48: 927. 31. Roy WL, Lerman J. Laryngospasm in pediatric anaesthesia. Can J
10. Weshtrope R N. The position of larynx in children and its relation to Anaesth 1988; 35: 93-98.
ease of intubation. Anaesth Intens Care 1987; 15: 384. 32. Fink BR. The etiology and treatment of laryngospasm in anesthesia.
11. Henderson JJ. The use of paraglossal straight blade laryngoscopy in Anesthesiology 1956; 17: 569-77.
difficult tracheal intubation. Anaesthesia 1997; 52: 552. 33. Leight P, Wisborg J, Chraemmer-Jorgenson. Does intravenous lignocaine
12. Berry F A. Anaesthesia for the child with a difficult airway. In Berry FA prevent laryngospasm after extubation in children? Anesth Analg 1985;
editor, Anaesthetic management of difficult and routine paediatric patients 64: 1993-96.
2 edn. New York, Churchill Livingstone 1990; 167-98. 34. Lee KWT, Downes JJ. Pulmonary edema secondary to laryngospasm in
13. Populaire C, Lundi JN, Pinaud M et al. Elective tracheal intubation in children: Anesthesiology 1983; 59: 347-49.
prone position for a neonate with Pirre Robin Syndrome. Anesthesiology 35. Downes JJ, Raphaely RC. Pediatric intensive care. Anesthesiology 1975;
1985; 62: 214 43: 238-50.
14. Johnson CM, Sims C. Awake fibreoptic intubation via laryngeal mask 36. Fernandes IC, Fernandes JC, Corderio A et al. Efficacy and safety of
in an infant with Goldenhar’s syndrome. Anaesth Intens Care 1994; 22: nebulized L- epinephrine associated with dexamethasone in postintubation
194-97. laryngitis. J Pediatr (RioJ) 2001; 77: 179-88.