A Framework For The Management Of The Pediatric Airway

This article aimed to produce, for the first time, an international consensus statement on the immediate basic management of paediatric airway complications and the anticipated and unanticipated difficult paediatric airway. The authors were from a range of paediatric tertiary units in the developed and developing world (UK, Canada, USA, Switzerland, New Zealand, Australia, Colombia) and 3 were editors for the publishing journal at the time of publication.

The approach from the authors was that of an emphasis on simplicity over complex algorithms which, to date have been largely, potentially over-extrapolated, from adult guidelines. Such over-extrapolation was felt to be inappropriate owing to a number of paediatric-specific factors such as poor apnoea tolerance. As a result, a ‘framework’ of underlying evidence-based principles is presented.

For the anticipated difficult airway, where there is not an immediate threat to ‘life or limb’, referral to a specialized center is highlighted as is the presence of ENT/ORL support in theatre pre-induction owing to the particularly high failure rate of non-specialist FONA attempts in children.

A distinction was made between ‘anatomical’ or ‘mechanical’ obstructions (such as from marked adenotonsillar hypertrophy) and ‘functional’ obstructions (such as from laryngospasm or opioid-induced muscle rigidity) with such functional forms of obstruction being far more common in children than in adults. The former are managed by direct mechanical maneouvres such as repositioning, airway adjuncts, alveolar recruitment and orogastric stomach decompression and the latter by drugs to deepen, or drugs to relax skeletal or bronchial smooth muscle. Readers are reminded of the value of intravenous 1mcg/kg adrenaline in managing the silent bronchospastic chest.

The authors also emphasised the preference of maintaining full neuromuscular blockade in the evolving CICO scenario over attempts to waken/reverse due to the lack of apnoeic reserve. Limiting intubation to a maximum of 2 attempts limits trauma-induced oedema that, in an already small airway may readily tip a critical airway over the edge.  With any sequential failure of standard anaesthetic airway manoeuvres, evidence around subsequent FONA vs rigid bronchoscopic rescue appears lacking and either technique is supported as first port of call for ‘plan C’. In specific instances where there is almost total obstruction to the upper airway and only a very small tube or hollow bougie/airway exchange catheter can be passed either through the cords or via FONA, the Ventrain system is supported as a unique method akin to low frequency jet ventilation to avoid stacking/barotrauma. This framework does indeed present a more accessible basic approach to paediatric airway problems, similar in nature to the ‘vortex approach’, as compared with its algorithm-driven counterparts, that can be applied in a range of facilities with varying paediatric expertise.

Reviewed by David Stoeter