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