Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

The design of the perfect pediatric supraglottic airway device

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the  supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of  supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

Craniofacial surgery and specific airway problems

Infants and children undergoing craniofacial surgery may present with a wide range of diseases and conditions posing an array of challenges to the anesthesiologist. Optimal perioperative care requires an understanding of these diseases and their impact on airway and anesthetic management. For those children with anomalies affecting airway anatomy, soft tissues of the head and neck, or skeletal mobility, advanced airway management techniques (ie, modalities other than direct laryngoscopy) may be required to secure the airway. Additionally, some craniofacial surgical procedures have direct implications on airway management, such as with Le Fort III midface advancement involving halo distractor application, where the distractor device precludes facemask ventilation. For all of these patients, the anesthetic and airway management plans must be tailored to the surgery being performed, the patient's specific conditions, and take into consideration all phases of perioperative care. In this review, we present some of the more commonly encountered craniofacial abnormalities affecting airway management.

Otolaryngologic Manifestations of Klippel-Feil Syndrome in Children

Importance

Children with Klippel-Feil syndrome (KFS), characterized principally by abnormal fusion of 2 or more cervical vertebrae, may have many additional congenital anomalies. The overall prevalence of otolaryngologic manifestations among patients with KFS has not been previously characterized.

Objective

To define the otolaryngologic diagnoses made and procedures performed in 95 patients with KFS, which, to our knowledge, is the largest series of this challenging patient population published to date.

Design, Setting, and Participants

For this retrospective review, all patients with KFS who underwent otolaryngology consultation at our institution over a 26-year period (January 1989 to December 2015) were included. Patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and were confirmed through individual medical record review. Relevant otolaryngologic diagnoses and procedures were extracted using ICD-9 and Current Procedural Terminology codes, respectively. Selected demographics included age, sex, number of clinic visits, and number of procedures.

Main Outcomes and Measures

The primary outcomes were the otolaryngologic diagnoses and procedures associated with the KFS patient population; the secondary outcome was Cormack-Lehane classification documented during airway procedures.

Results

Overall, 95 patients with KFS were included in this study (55 males [58%] and 40 females [42%]); mean (range) age at time of presentation to the otorhinolaryngology clinic was 5.8 (birth-23.0) years. Each patient with KFS averaged 8 visits to the otorhinolaryngology office and 5 otolaryngologic diagnoses. The most common diagnosis was conductive hearing loss (n = 49 [52%]), followed by sensorineural hearing loss (n = 38 [40%]), and dysphagia (n = 37 [39%]). Sixty-two (65%) patients underwent otolaryngologic procedures, with 44 (46%) undergoing multiple procedures. The most common procedure was tympanostomy tube placement (n = 36 [38%]), followed by office flexible endoscopy (n = 23 [24%]). Twelve of the 20 patients who underwent direct laryngoscopy had documented Cormack-Lehane classification; 5 of 12 patients (42%) had a compromised view (grade 2, 3, or 4) of the larynx. Three patients required tracheotomies at this institution for airway stabilization purposes; each had severe upper airway obstruction leading to respiratory failure.

Conclusions and Relevance

Patients with KFS require consultation for a variety of otolaryngologic conditions. Among these, hearing loss is the most common, but airway issues related to cervical spine fusion are the most challenging. Formulating an appropriate care plan in advance is paramount, even for routine otolaryngology procedures.

AMBU® LMA® in Children With Cleft Palate for Ophthalmic Surgery: A Case Report

Airway management remains a challenge in children, and the presence of a cleft palate further complicates the scenario. Endotracheal intubation, although definitive and most preferred, may be avoided for certain short-duration procedures wherein the use of laryngeal mask airway can allow quicker emergence. We present the successful airway management of 2 pediatric patients with cleft palate undergoing ophthalmological surgery, using AMBU® LMA® as the airway device of choice, which was further used as a rescue airway device in an emergent situation of "difficult to ventilate."

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video-Assisted Laryngoscopy

Objective

Difficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees.

Study Design

Randomized crossover pilot study.

Setting

Tertiary academic medical center.

Methods

Twenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds.

Results

Direct laryngoscopy demonstrated a significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1) versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9) and LMA placement (36.6 seconds; 95% CI, 24.7-48.4).

Conclusions

Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.