Pediatric Airway | Srna Senior Project

Assessment of pediatric airway

Assessment of difficult airway in pediatric patients, as in adults begins with a comprehensive history and physical examination.

History:

Questions regarding complaints of snoring, apnoea, day time somnolence, stridor, hoarse voice and prior surgery or radiation treatment to face or neck should be made. This information may indicate hypoxemia and pulmonary hypertension. History should also consist of a review of previous anaesthetic records with attention being paid to history of oropharyngeal injury, damage to teeth, awake tracheal intubation or postponement of surgery following an anaesthetic.

Physical examination:

It should focus on the anomalies of face, head, neck and spine.

• Evaluate size and shape of head, gross features of the face; size and symmetry of the mandible, presence of sub-mandibular pathology, size of tongue, shape of palate, prominence of upper incisors, range of motion of jaw, head and neck.

• The presence of retractions (suprasternal/sternal/infrasternal/ intercostal) should be sought for they usually are signs of airway obstruction.

• Breath sounds – Crowing on inspiration is indicative of extrathoracic airway obstruction whereas, noise on exhalation is usually due to intrathoracic lesions. Noise on inspiration and expiration usually is due to a lesion at thoracic inlet.

• Obtaining blood gas and O2 saturation is important to determine patient’s ability to compensate for airway problems.

• Transcutaneous CO2 determinations are very helpful in infants and young children. Many investigators have attempted to develop methods that predict a difficult laryngoscopy in this age group. These methods have been primarily studied in adults and have variable sensitivity in children.

Mallampati classification does not accurately predict a poor view of glottis during direct laryngoscopy in pediatric patients.

Several tests may be done to predict a difficult airway in children.

a. Plain radiography – For evaluation of nasopharynx, pharynx, subglottic lesion and trachea.

b. CT scan and MRI can detect choanal atresia, lymphatic malformation of neck, mediastinal masses etc.

c. Direct or indirect endoscopy of the upper and lower airway for functional assessment and diagnosis of a pathology in nasopharynx, supraglottic, glottic and subglottic areas.

d. Fluoroscopy – For assessment of dynamic pathology e.g. airway malacia specially when stridor, cough and dysphagia are present.

e. USG studies – To assist in evaluation of functional and organic airway disorders, assess the dynamic state of certain pathologies.

f. Pulmonary function studies can provide valuable information about patency of airway passages.

Infants and children present with anatomic, physiologic and physiological challenges that differ from adults. There is NO one-way to manage children with difficult airways. While flexible bronchoscopy remains an indispensible tool, other recently introduced tools such

as the GlideScope offer significant advantages in many situations.

What makes the pediatric airway different?

• Large occiput

• Narrow nares

• Large tongue

• High larynx, C3-4

• Narrow cricoid

• Thyromental distance about 1/2 that of an adult

• Soft laryngeal cartilages and tracheal rings

• Often have loose teeth

Assessment of external anatomy:

• Micrognathia (undersized jaw)