Pediatric Airway Series: Part 4 – The Difficult Airway

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February 13, 2018 by Agnes Usoro

What is a Difficult Airway?

  • The American Society of Anesthesiologists defines a difficult airway as one in which there is:
    • Difficulty with bag-mask ventilation, and/or
    • Difficulty with tracheal intubation
  • Additional characteristics that would classify someone as a difficulty airway include:
    • When > 2 attempts are required for tracheal intubation with the same blade
    • The need to change the blade for tracheal intubation
    • An alternative intubation technique is required for tracheal intubation
    • The need for a rescue device

Difficult Airway Scenarios in Pediatrics:

Upper airway infection: Epiglottitis

These children appear toxic and may be drooling on presentation, indicating advanced upper airway obstruction. Upper airway swelling makes direct laryngoscopy difficult. In this situation always have supraglottic devices handy for rescue. The ideal situation is to have the child intubated in a controlled environment such as the operating room with Anesthesia or Otolaryngology specialists.

Foreign Body Obstruction: Tracheal Grape Impaction

In an unconscious child with an upper airway foreign body obstruction, attempt direct laryngoscopy to attempt to visualize the impacted object. If you are able to visualize the foreign object, use Magill forceps to remove it. If the obstruction is subglottic and nonvisible, intubate and push the foreign object into the main-stem bronchus. Emergent bronchoscopy is needed to eventually remove the object. Cricothyrotomy is usually not helpful in this situation given that the obstruction is usually below the cricothyroid membrane.

Recall that an open surgical cricothyrotomy is NOT an option for children less than the age of ten. In this age group, needle cricothyrotomy is recommended.

Airway Anomaly: Micrognathia

Micrognathia is a small lower jaw with a receding chin, which increase the chance of upper airway obstruction by pushing the tongue back up against the larynx. This obstruction can be relieved with positive pressure (bag-mask ventilation) or placement of a laryngeal mask airway. Micrognathia also makes it difficult to visualize the airway with direct laryngoscopy. Therefore, utilize video laryngoscopy to improve your success for tracheal intubation.

Rescue Devices to be familiar with!

Supra-glottic Device: Laryngeal mask airway (LMA)

Screen Shot 2018-02-08 at 10.22.07 PM.png

Magill Forceps


Screen Shot 2018-02-08 at 9.08.19 PM.png

Needle Cricothyrotomy

Pay attention to the supplies you have as the materials vary***

  • 14g catheter
  • 3.0mm ETT adapter + 10 mL syringe OR
  • 7.0mm or 7.5mm ETT adapter + 3mL syringe

Screen Shot 2018-02-08 at 10.35.20 PM.png

Screen Shot 2018-02-08 at 10.35.32 PM.pngScreen Shot 2018-02-08 at 10.35.50 PM.png

Video Laryngoscopy


Post Intubation Management to be discussed in Part 5 of the Pediatric Airway Series



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