Normal and difficult airways in children: “What’s New”—Current evidence

Abstract

Background Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit. Methods Expert review of the recent literature. Results Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation–associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration. Conclusion Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.

Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children

“…This finding is consistent with recent anesthesia literature that report NMB administration may be a useful intervention to mitigate difficult BMV, except in children with extrinsic or intrinsic large airway compression. 1 32 33 34 35 36 Future study is needed to identify the appropriate indications and timing for NMB administration for children with anticipated or unanticipated difficult BMV.…”

Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device

“…Given the differences in intubation technique between VL and DL, this translation between blade size and age (or weight) groups may not be so straightforward. 19 A recent randomized controlled trial in neonatal intubation found the larger size 2 Glidescope was associated with shorter time to intubation than a size 1 Glidescope blade. 20 Case reports of the use of an oversize C-MAC D-blade in pediatric patients with a difficult airway have recently been reported.…”

“…Video laryngoscopy sizing has been taken directly from DL practice. Given the differences in intubation technique between VL and DL, this translation between blade size and age (or weight) groups may not be so straightforward 19 . A recent randomized controlled trial in neonatal intubation found the larger size 2 Glidescope was associated with shorter time to intubation than a size 1 Glidescope blade 20 .…”

Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS

“…Kaplan et al initially described the use of VL by experienced laryngoscopists in adult patients in whom TI was anticipated to be difficult [ 5 ]. Since, the VL has become widely used for anticipated or confirmed difficult intubations in adults, children and newborn [ 20 , 22 , 24 ]. The VL used in the majority of the NICUs in this study is the C-MAC VL (Karl Storz ©,Tuttlingen, Germany) which currently offers Miller blades 0 and 1.…”