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Managing Difficult Pediatric Airways

Managing Difficult Pediatric Airways


A recent study shows that pediatric anesthesiologists may not spot the difficult intubation as easily as some might think. Children are less susceptible to airway management problems, so information about difficult airways is limited, according to the Manual of Emergency Airway Management. With this in mind, investigators with The Hospital for Sick Children in Toronto reviewed anesthetic records to learn more about the problem.

The Canada Study

Researchers examined the records of children ranging from newborn to 17 years old looking for common features associated with the difficult intubations. The records were for children that underwent general anesthesia at the pediatric tertiary care center between 2009 and 2011. One investigator involved with the project stated that their goal was to draw conclusions from the available data and learn what they could from it.

The scientists reviewed 22,766 cases and analyzed key elements such as:

  • Incidence
  • Demographics
  • Airway history
  • Physical assessment
  • Airway management details
  • Complications

Their conclusion was that one-fifth of the patients, 94 in-total, experienced a difficult airway incident five out of every 1,000 anesthetics. Adolescent patients older than 13 represented almost half of the cases and infants under that age of one made up an additional 21 percent. More than half of the hard intubations involved patients that had undergone previous tubings that were without incident.

At the 2015 annual Canadian Anesthesiologists’ Society gathering, one study author stated that 80.6 percent of the problems were anticipated. Although happy with that number, it did show that almost 20 percent of difficult intubations came as a surprise. The goal was to look for markers that might warn the anesthesiologist in those cases. Developing a high index of suspicion would allow physicians to create better alternative strategies for pediatric patients with an unanticipated difficult airway.

Managing Difficult Airways

The study authors broke down the data to see how anesthesiologists managed those difficult airways, as well. They determined difficult airway management, even when not expected, was successful 91 percent of the time with tracheal intubation, 5.6 percent with laryngeal mask airway, 1.6 percent with nasal prongs and 1.6 percent with a face mask. The data showed:

  • Direct laryngoscopy worked in 53 patients with an anticipated difficult airway
  • Four emergency tracheotomies and two rigid bronchoscope intubations were done after failed attempts to intubate.
  • Thirty-eight intubations in adolescent patients were performed with only airway topicalization. The patients remained awake during the procedure.
  • Thirty-four patients required admittance to the pediatric ICU

The good news is that all the surgeries were done despite the difficult airway management. The researchers did think it was surprising that so many of the problems were unanticipated, though. The study showed it is not as easy to spot a tough intubation in children as pediatric anesthesiologists would like to believe.

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