Controversies in Pediatric Perioperative Airways

Abstract

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

Oral endotracheal intubation in pediatric anesthesia

“…Based on this traditional anatomical concept of the pediatric airway, it has generally been accepted that uncuffed ETTs should be used for children younger than 8 years. This approach has the benefits of achieving a larger internal diameter (ID) of the tube, reducing airway resistance, and minimizing the incidence of edema formation due to mucosal damage caused by cuffs [1].…”

“…ETT size should be standardized based on internal tube diameter, since external diameter varies among manufacturers [2]. The size of uncuffed tubes can be estimated using Cole's formula [ID (mm) = (16 + age) / 4] for children > 2 years [1].…”

“…Age-based formulae for ID may not be accurate, and we should therefore prepare ETTs with IDs 0.5 mm larger or smaller than the calculated size [1,6]. An air leakage test with a sustained inflation pressure of 20 to 25 cmH 2 O is recommended after intubation to confirm the correct tube size.…”

“…Cuffed ETT size may be calculated by the Khine formula [ID (mm) = (age in years / 4) + 3], and is smaller than the predicted ID of uncuffed tubes for patients of a given age [1,2]. Thus, cuffed ETTs may be 1-2 sizes smaller than uncuffed ETTs calculated with Cole's formula [1,2].…”

Airway in the Newborn Patient

“…See table for most frequent morphological syndromes in the newborn (Table 1 & 2). Unexpected difficult face mask ventilation in children varies from 2.8 to 6.6% and the incidence of difficult endotracheal intubation varies between 0.06% and 1.34% [3].…”