A framework for the management of the pediatric airway

Abstract

Summary Critical airway incidents in children are a frequent problem in pediatric anesthesia and remain a significant cause of morbidity and mortality. Young children are at particular risk in the perioperative period. Delayed management of airway obstruction can quickly lead to serious complications due to the short apnea tolerance in children. A simple, time critical, and pediatric‐specific airway management approach combined with dedicated teaching, training, and frequent practice will help to reduce airway‐related pediatric morbidity and mortality. There is currently no pediatric‐specific universal framework available to guide practice. Current algorithms are modifications of adult approaches which are often inappropriate because of differences in age‐related anatomy, physiology, and neurodevelopment. A universal and pragmatic approach is required to achieve acceptance across diverse pediatric clinicians, societies, and groups. Such a framework will also help to establish minimum standards for pediatric airway equipment, personnel, and medications whenever pediatric airway management is required.

Emergency intubation of children outside of the operating room

“…When planning for routine anesthesia, the American Society of Anesthesiologists suggests that four decisions need to be made: awake or asleep intubation, spontaneous ventilation (SV) or ablation of SV, noninvasive (face mask/ SGA) or invasive airway (ETT/ front‐of‐neck access (FONA)) techniques, and direct or indirect laryngoscopy . In children, awake intubation is rarely an option, and the equipment for SV (inhalational or total intravenous anesthesia (TIVA)) and flexible video bronchoscopic techniques may not be immediately available in non‐OR settings . In recognition of the low first pass success rate during non‐OR airway emergencies, in addition to this initial plan, it is important to plan for subsequent attempts in order to avoid fixation error .…”

“…(1) Face‐mask oxygenation is the primary form of pre‐ and re‐oxygenation (in the event of unsuccessful intubation). If this proves difficult, airway patency should be ensured by ensuring adequate depth of anesthesia/ muscle relaxation, optimizing head position, basic airway opening maneuvers of chin lift or jaw thrust, and insertion of an oro‐ and/or nasopharyngeal airway . Improved face‐mask seal may be obtained using a two‐person technique.…”

Visual aids for pediatric airway management

“…Not uncommonly, pediatric airway problems occur when the anesthesia or intensive care team has limited experience of children. These specific problems are discussed in the recently published framework for the management of the pediatric airway …”

Description and function of a difficult airway service

“…Practice guidelines addressing the difficult airway in adults have improved the safety of clinical practice by reducing the need for an emergency surgical airway intervention . Consensus guidelines for the pediatric patient are similar in framework to the approach suggested for the difficult adult airway In contrast to adults, the unexpected difficult airway represents a smaller proportion of the difficult airway population as numerous congenital conditions often caution the pediatric specialist to suspect a difficult airway. The difficult airway in a child, like an adult, is defined as a patient who is difficult to provide effective bag‐mask ventilation and/or who is challenging to intubate.…”

“…This approach assures an expert in airway management can assist in the care of a critically ill child. In the child who has a congenital or acquired airway abnormality, emergency airway management is often challenging and often requires additional help and specialized equipment . When a difficult airway is encountered in a child, the morbidity and mortality are reported to be greater than in adults .…”