Tips and Tricks for the Difficult Pediatric Airway

Educational Objectives

The goal of this program is to improve the management of difficult pediatric airways. After hearing and assimilating this program, the clinician will be better able to:

1. Appraise the methods for managing difficult airways in children.

Summary

Airway: airway management is fundamental in resuscitating critically ill or injured children; understanding pediatric airway characteristics is crucial for predicting and addressing difficult airway (DA) scenarios

DA in pediatrics: characterized by challenges with ventilation or intubation; pediatric airways are challenging, with a 6% difficulty rate in bag-valve-mask (BVM) ventilation, 4-fold higher than that in adults; failure rate of first-pass intubation is 5% in children <1 yr of age; anatomic differences in the pediatric airways exacerbate these difficulties; children’s smaller airways make them more susceptible to obstruction from edema; other differences include larger tongues relative to the oropharynx, a prominent occiput, a long floppy epiglottis, and a funnel-shaped airway where the cricoid cartilage forms the narrowest point; the pediatric larynx is more anterior and superior, requiring more acute angles for visualization during intubation

Indicators of DA: include limited mouth opening, prominent central incisors, cervical spine immobility (eg, trauma, Down syndrome), and large tongue; Pierre Robin sequence (characterized by micrognathia, a receding chin, and a disproportionately large tongue) also predicts DA; additional predictors include short neck, obesity, laryngeal edema, inflamed epiglottis from infections or burns, and facial trauma

Management of DA: the same fundamental strategies used in adults are required; BVM ventilation remains a cornerstone but fails more frequently in children than desired, particularly in emergency settings; jaw thrust is used to alleviate airway obstruction caused by the relatively larger tongue in children; this maneuver is crucial for successful BVM ventilation, which is vital for stabilizing the child during multiple intubation attempts; proper positioning is essential, particularly in children <2 yr of age; instead of placing a towel under the occiput as with older patients, a smaller support (eg, washcloth) under the shoulders helps align the airway without hyperextending the neck; effective BVM ventilation demands a 2-person technique whenever resources allow; this approach reduces the risk of creating airway obstruction by pressing down too hard on the mask, which can force the tongue further into the oropharynx; instead, lifting the jaw into the mask while achieving a proper seal is emphasized; techniques (eg, E to C grip, thenar technique) are effective, but care must be taken to lift rather than push to ensure airway patency and minimize stress during resuscitation

Rapid sequence intubation (RSI): once BVM ventilation is successful, prepare for RSI; this is not the time to experiment with new intubation techniques; use familiar methods instead; the first attempt is usually the best chance for success, so take time to optimize conditions; have backup plans in place; unlike adults, pediatric airway management requires calculating the endotracheal tube size and depth; a common formula is age/4 plus 4 for uncuffed tubes or age/4 plus 3.5 for cuffed tubes; sedation and paralytic agents must be carefully dosed, and additional medications (eg, atropine) should be considered, especially in children <2 yr of age; proper tube depth is typically calculated as 3 times the tube size in centimeters at the gumline or teeth; in cases of failure, backup plans (eg, video laryngoscopy) should be ready; supraglottic devices can provide temporary ventilation while planning further interventions

Surgical options: when neither intubation nor ventilation is successful, a surgical airway must be considered; needle cricothyrotomy is often the preferred approach in children <8 yr of age because of their small cricothyroid membrane (≈5 x 5 mm²); this involves placing a needle directly into the trachea for transtracheal jet ventilation

Readings

Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31-81. doi: 10.1097/ALN.0000000000004002; Krishna SG, Bryant JF, Tobias JD. Management of the difficult airway in the pediatric patient. J Pediatr Intensive Care. 2018;7(3):115-125. doi: 10.1055/s-0038-1624576.

Disclosures

For this program members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Scarboro was recorded at the 2024 Rocky Mountain Winter Conference, held February 24-28, 2024, in Steamboat Springs, CO, and presented by Well Assembled Meetings. For information about upcoming CME activities from this presenter, please visit https://wellassembled.com/events. Audio Digest thanks the speakers and Well Assembled Meetings for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

EM420503

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.