Airway management in neonates and infants

Abstract

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong ‘1’ or weak ‘2’ recommendation with high ‘A’, medium ‘B’ or low ‘C’ quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Emergency front‐of‐neck access in pediatric anesthesia: A narrative review

“…4 In the recently published guidelines on neonatal and infant intubation, a clinical practice statement is made, that surgical tracheotomy should be performed when intubation fails, oxygenation and ventilation via a supraglottic device or face mask are severely impaired or impossible and spontaneous breathing cannot be restored. 32,33 The anatomical features of children should always be taken in consideration when an eFONA is going to be performed. Based on Navsa et al, 34 the mean dimensions of the cricoid membrane in neonates is 2.6 mm in height and 3.0 mm in length, indicating that a tracheal tube with an outer diameter exceeding 2.5 mm is too wide for the relatively narrow cricothyroid membrane, and may cause damage to the surrounding structures.…”

“…In the recently published guidelines on neonatal and infant intubation, a clinical practice statement is made, that surgical tracheotomy should be performed when intubation fails, oxygenation and ventilation via a supraglottic device or face mask are severely impaired or impossible and spontaneous breathing cannot be restored 32,33 …”

Can video laryngoscopy and supplemental oxygen redefine pediatric, infant and neonatal tracheal intubation standards?

“…These authors also emphasize the importance of situational awareness and close attention to human factors ( 2 ). These recommendations are resumed and reinforced in the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia Guidelines on neonates’ and infants’ airway management ( 24 ).…”

“…Pediatric TI can present many challenges. Attention should be paid to the unique characteristics of pediatric and neonatal airways and respiratory physiology to prepare for potential adverse events specific to this population ( 1 , 2 , 24 ). The number of TI attempts matters, and achieving TI within a limited number of attempts relies on several factors beyond professional expertise.…”

“…The European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia Guidelines on neonates’ and infants’ airway management highlight these strategies, among other recommendations ( 24 ). These guidelines recommend VL with an age-adapted standard blade (Macintosh or Miller) as a first choice for TI in neonates and infants (strong recommendation, moderate evidence quality) as well as AO in neonates (strong recommendation, moderate evidence quality).…”