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| EDITORIAL |
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| Year : 2020 | Volume
: 3
| Issue : 3 | Page : 107-109 |
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Managing the difficult paediatric airway: The conjuror's bag of tricks
Elsa Varghese1, Nandini Dave2
1 Former Professor and Unit Head, Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
2 Senior Consultant and Head of Department of Anaesthesiology, SRCC NH Children's Hospital, Mumbai, Maharashtra, India
| Date of Submission | 03-Dec-2020 |
| Date of Acceptance | 04-Dec-2020 |
| Date of Web Publication | 25-Dec-2020 |
Correspondence Address:
Dr. Nandini Dave
SRCC NH Children's Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/arwy.arwy_57_20
How to cite this article:
Varghese E, Dave N. Managing the difficult paediatric airway: The conjuror's bag of tricks. Airway 2020;3:107-9 |
This issue of Airway has a number of articles related to difficult airway in children. Observing laryngeal views in children under the age of 2 years with the paraglossal and midline approaches using a size 1 Miller blade, Roychoudhury et al. conclude that the midline approach 'does not necessarily provide a good view of the larynx in small children and that the paraglossal approach is equally effective'.[1] There has been increasing interest in revisiting the use of the Miller blade in small children and comparing it with the Macintosh blade. Two independent studies by Varghese et al. and Passi et al. confirm that in infants and small children, optimal laryngeal views may be obtained with either of these blades.[2],[3] These studies also emphasise that anaesthesiologists should not only familiarise themselves with both the blades in infants but also insert the Miller blade as one does the Macintosh blade to minimise the risk of vagal stimulation. The paraglossal approach provides additional advantage in children with cleft lip and palate, wherein the laryngoscope blade can be introduced from the side of the mouth, thereby preventing slipping of the blade into the cleft and avoiding inadvertent pressure from being applied to prominent structures such as a protruding premaxilla.
While debating the blade design that is ideal in children, the potential problems of a modified size zero Macintosh blade, with an abrupt curvature and the web and flange ending in the mid portion of the blade, have been highlighted in this issue by Rudingwa et al.[4] The authors observe that while the absence of the web at the distal end of the blade renders it narrower to possibly allow easier insertion, it also causes the tongue to hang over the blade, obliterating the space available to insert an endotracheal tube in infants. 'New improved' versions of airway equipment are frequently introduced into the market with the intention of providing advantages over the existing designs. However, it is up to the experienced user to critically evaluate new designs before accepting these into their practice. It would be even better if well-designed, robust and unbiased studies are conducted to evaluate new blade designs against blades of the original design before a modification is accepted into clinical practice.
With the COVID-19 pandemic taking centre stage for most of 2020, it is but natural that we look for creative ideas to prevent the spread of the virus in our work environment, especially so in resource-poor countries. Gupta et al. have described a simple technique to perform oropharyngeal suction as an alternative to closed in-line suction with a view of minimising surface contamination.[5] The suction catheter is retained within the original plastic cover with just-enough length of the distal end exposed to be inserted into the airway. The authors describe how suctioning can be performed while holding the catheter inside its cover and withdrawing the catheter into its cover after use. This recommendation to use inexpensive non-touch techniques is the need of the hour while we look towards cutting costs while still maintaining a safe working environment.
Securing the difficult airway, especially in a syndromic child, makes us think on our feet and be innovative. Three case reports in this issue do exactly that. Amburu et al. report a child with Goldenhar syndrome and an anticipated difficult airway undergoing ophthalmic surgery. While surgery commenced with a supraglottic airway device (SAD), an intraoperative decision was made for surgical reasons to intubate the child.[6] The authors report successful blind intubation performed through the SAD in the absence of a fibreoptic bronchoscope (FOB). While they were fortunate, this technique is fraught with risks and cannot be recommended routinely. FOB-guided intubation via an SAD ensures smooth passage through the glottis, thereby avoiding possible trauma by blind insertion. There are several studies which have clearly demonstrated that despite apparent unobstructed breathing through an SAD, the large epiglottis in an infant often flops backwards onto the distal end of the SAD.[7],[8] Blind intubation through an SAD can cause impingement onto delicate supraglottic structures, resulting in trauma. Data from the Multicentric Pediatric Difficult Intubation Registry indicate that fibreoptic intubation through an SAD is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways.[9] Meticulous planning and discussion with surgical colleagues can help avoid such last-minute changes in plans, thereby enhancing patient safety.
This issue also reports a preterm baby with Pierre Robin sequence who presented for glossopexy.[10] An Ambu® laryngeal mask airway could be placed in this baby and anaesthesia with muscle relaxation could be provided. Because a small FOB (2.2 mm OD) was not available, a soft-tipped urological guide wire was passed retrograde via a 22G spinal needle cricotracheotomy which emerged smoothly through the proximal end of the SAD. The guide wire was threaded through the Murphy's eye of a 2.5 mm ID endotracheal tube to decrease the chance of dislodgement. While the endotracheal tube was being railroaded over the guide wire, nasal oxygenation was continued to prevent hypoxaemia. The authors do not mention whether the baby desaturated at any point. The use of the cricotracheal membrane in this case is justified as it provides a few additional millimetres of length for manoeuvring when advancing the endotracheal tube and removing the guide wire than if the cricothyroid membrane is punctured. It also results in less trauma to the vocal cords. It would be important however to confirm this with a follow-up of this child to know the long-term complications of the procedure. While the use of muscle relaxants is questionable, the likelihood of the guide wire passing freely past relaxed vocal cords is higher than if the vocal cords were moving or apposed. As emphasised by airway algorithms laid down by difficult airway societies across the globe,[11],[12] the importance of oxygenation at all times during the process of securing the airway was honoured throughout the process of retrograde intubation by the authors.
Videolaryngoscopy certainly is a boon and should be made available when economically feasible. A prospective cohort analysis of airway management complications in children with difficult airways suggests that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails enhances patient safety.[13]
Mundotiya et al. describe the problems faced when anaesthetising a 20-month-old child with developmental dysplasia of the hip which turned out to be a very difficult intubation needing multiple attempts.[14] In these situations when a Grade 3b view is obtained, it helps to mould the distal end of the endotracheal tube into a J-shape with the help of a stylet, or intubate over a bougie or a tube exchanger. The importance of having a paediatric tube exchanger available in all operating rooms cannot be emphasised enough. Informing the family is also crucial, as was evident in this case. The child required a second procedure where intubation was difficult again.
The report of a 3-year-old with severe degree of post-burn contracture neck is a nightmare, fortunately infrequently encountered nowadays due to progress in burns care.[15] The authors were unable to pass an FOB via the nose as the nares were narrowed. This case illustrates that it is difficult to obtain a view of the larynx when there is acute neck flexion especially when the FOB is passed via the mouth. Fortunately, the child could be anaesthetised via a facemask and following videolaryngoscopy, the endotracheal tube was passed over a bougie. This report stresses the importance not only of thinking of all possible airway management strategies but also of having equipment and experienced personnel at hand to release the burn contracture prior to intubation.
Institutions, and individual anaesthesiologists, would do well to assemble a 'Difficult airway cart' to manage airway contingencies. These should be located in an identified central location and the contents should be regularly checked by a designated individual. Human factors can well impact clinical performance, especially during airway emergencies. Standardisation of equipment and protocols and regular training of all end users will go a long way in ensuring safe management of the difficult airway.[16]
It needs to be stressed that the paediatric difficult airway should only be managed by experienced personnel as the margin of error is very slim. Multiple attempts using the same technique are to be avoided. A well-thought-out strategy and a simple step-wise approach, with a change in technique or management as indicated, goes a long way in improving outcomes. Anaesthesiologists have a responsibility to be familiar with airway algorithms, keep themselves updated and make pragmatic modifications with the available resources. When it comes to difficult intubations, it is not just enough for one to have several tricks up one's sleeve. One also needs to familiarise oneself with various approaches and be able to use them wisely when required.
| References | |  |
| 1. | Roychoudhury S, Kundu R, Murmu R, Mistry T, Paul D, Chatterjee AB. Midline versus paraglossal laryngoscopic approach using the Miller blade in small children: A randomised, controlled, cross-over study. Airway 2020;3:127-34.  [Full text] |
| 2. | Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and i?ntubating conditions than the Macintosh blade in small children? Paediatr Anaesth 2014;24:825-9. |
| 3. | Passi Y, Sathyamoorthy M, Lerman J, Heard C, Marino M, Thompson JP. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 year of age. Br J Anaesth 2014;113:869-74. |
| 4. | Rudingwa P, Arasu M, Kannamani B, Panneerselvam S. A variation in the Macintosh laryngoscope design: Is it really helpful? Airway 2020;3:159-60. [Full text] |
| 5. | Gupta A, Puri S. Airway suctioning during the COVID-19 era: A simple method to minimise surface contamination. Airway 2020;3:154-6. [Full text] |
| 6. | Amburu V, Soni SL, Gourav KP, Naik N. Blind tracheal intubation through Ambu AuraOnce™ in a child with Goldenhar syndrome for ophthalmic surgery. Airway 2020;3:163-5. [Full text] |
| 7. | Brimacombe J, Berry A. A proposed fiber-optic scoring system to standardize the assessment of laryngeal mask airway position. Anesth Analg 1993;76:457. |
| 8. | Van Zundert AAJ, Kumar CM, Van Zundert TCRV. Malpositioning of supraglottic airway devices: Preventive and corrective strategies. Br J Anaesth 2016;116:579-82. |
| 9. | Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT, et al. Videolaryngoscopy versus fiber-optic intubation through a supraglottic airway in children with a difficult airway: An analysis from the multicenter pediatric difficult intubation registry. Anesthesiology 2017;127:432-40. |
| 10. | Karuppiah N, Mohanty SK, Prasad S. Neonatal Pierre Robin sequence: An airway challenge addressed with retrograde intubation. Airway 2020;3:148-50. [Full text] |
| 11. | Pawar DK, Doctor JR, Raveendra US, Ramesh S, Shetty SR, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth 2016;60:906-14. [ PUBMED] [Full text] |
| 12. | Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth 2010;20:454-64. |
| 13. | Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the pediatric difficult intubation (PeDI) registry: A prospective cohort analysis. Lancet Respir Med 2016;4:37-48. |
| 14. | Mundotiya S, Palta S, Saroa R, Chhabra S. C-MAC® videolaryngoscope in difficult paediatric airway: Need to update our perspective. Airway 2020;3:144-7. [Full text] |
| 15. | Chhabra V, Jain MK, Sharma A, Singh S. Failed fibreoptic bronchoscopy-guided intubation in a child with post-burn contracture and anticipated difficult airway: Videolaryngoscope to the rescue. Airway 2020;3:140-3. [Full text] |
| 16. | Chrimes N, Bradley WPL, Gatward JJ, Weatherall AD. Human Factors and the 'next generation' airway trolley. Anaesthesia 2019;74:427-33. |
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