Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time.

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding: None.

Unanticipated difficult airway after prolonged use of a laryngeal mask airway.

The laryngeal mask airway (LMA) is recognized as a safe alternative to endotracheal intubation for short-term airway maintenance. In this case report we present the case of a term neonate with upper airway obstruction which was managed with a deflated LMA for 7 consecutive days. Despite previous reports of extended LMA use in neonates without complications, this patient experienced significant pharyngeal mucosal injury and edema, leading to difficulty with subsequent intubation attempts.

Management of the Normal and Difficult Pediatric Airway: Unique Challenges in the Time of COVID-19.

Purpose of Review: This review focuses on the challenges faced by acute care healthcare workers in the management of the normal and difficult pediatric airway during the COVID-19 pandemic and how these protocols and practices evolved during the pandemic. The current state of knowledge on timing of surgery and anesthesia is also discussed. Recent Findings: In the early days of the pandemic, information about the SARS-CoV-2 virus and disease process was scarce. Governmental, healthcare, and professional organizations created several guidelines to protect invaluable healthcare workers from the contagious virus while also delivering appropriate care to children with COVID-19. With the emergence of new studies and the deployment of new life-saving COVID-19 vaccines and other therapies, these guidelines evolved. The use of aerosol containment devices such as aerosol boxes and flexible barrier techniques was found to be ineffective in reliably containing virus particles while posing potential harm to both healthcare workers and patients. Also, the definition of aerosol-generating and dispersing medical procedures was vastly broadened. To date, use of appropriate personal protection equipment and COVID-19 vaccination are the most effective ways to protect healthcare workers and safely manage children infected with SARS-CoV-2 who require airway intervention. Summary: Evidence-based public health measures and appropriate personal protective equipment remain the best way to protect both healthcare workers and patients. As the virus and population evolve and COVID-19 vaccines become more widely available, clinicians must be willing to adapt to the emerging evidence of their impact on how safe pediatric perioperative care is delivered.

A clinical prediction of skin to subarachnoid space depth in parturients undergoing caesarean delivery in a Nigerian population.

Few studies on the prediction of skin to subarachnoid space depth (SSD) in African parturients undergoing caesarean delivery are available. We undertook a prospective observational study of 402 parturients scheduled for elective caesarean delivery to determine simple and clinically applicable formulae for predicting skin to SSD. Additionally, the impact of patient characteristics and variables such as age, height, weight, body mass index (BMI), and body surface area on SSD was studied. We employed a Stepwise Multiple Linear Regression Model to predict SSD in normal weight, overweight, and obese parturients using previously described formulae and compared our derived SSDs to these previous formulae for concordance. (Craig, Abe, Stocker, Chong's modified, Prakash, Ma, Hazarika, Taman and Celik). Mean SSD was 6.62 ± 1.07 cm in the overall population. SSD in normal weight patients was (6.19 ± 0.92 cm), overweight (6.44 ± 0.92 cm) and obese (6.97 ± 1.17 cm). There was a correlation between SSD and BMI (p = 0.001). Formulae for predicting SSD in the overall population, normal weight, overweight and obese parturients were 4.34 + weight × 0.03, 4.43 + weight × 0.03, 4.54 + weight × 0.03 and 3.56 + weight × 0.03, respectively. We also found the Prakash formula to correlate best with our observed SSD. We concluded that SSD correlated well with weight in the overall parturient population and that Prakash's formula was the most accurate of the other previously described formulae in predicting SSD in this subset of African parturients.

What is already known on this subject? Various formulae exist for predicting skin to subarachnoid space depth in adult patients and parturients.What the results of this study add? New formulae for predicting skin to subarachnoid space in a subset of African parturients are described and only one of the previously described formulae was found to reliably predict depth of the subarachnoid space in this cohort.What the implications are of these findings for clinical practice and/or further research? Formulae for the determination of skin to subarachnoid space depth using weight alone can be predictive for normal, overweight and obese parturients. Knowledge of the predicted depth can help guide appropriate needle selection and minimise wastage, especially in resource poor countries.

Anesthetic Challenges of an Adolescent Patient with Epidermolysis Bullosa and Gitelman's Syndrome Undergoing Posterior Spinal Fusion Surgery.

Surgical correction for scoliosis is undertaken to avoid progression to cardiopulmonary compromise as well as improve the patient's overall quality of life. In this case report, we presented a case of a 14-year-old girl with epidermolysis bullosa simplex and Gitelman's syndrome who underwent posterior spinal fusion for scoliosis. The perioperative planning and intraoperative management of a patient with this unique combination of comorbidities undergoing a complex, high-risk surgical procedure were not previously chronicled in the literature. We detailed the steps undertaken to optimize the patient prior to surgery and the unique intraoperative surgical and anesthetic considerations that led to a successful completion of the surgery and recovery.

Determining the Odds of Difficult Airway Resolution Among Pediatric Patients: A Case Series.

OBJECTIVE: We sought to determine the patient factors that contribute to the improvement and resolution of difficult airways in pediatric patients. STUDY DESIGN: The hospital's Multidisciplinary Airway Registry Committee was created in November 2006 to develop a process for recognition and management of children with difficult airways. A database of these patients is actively maintained, allowing for statistical data analysis. SETTING: The tertiary care hospital system consists of 2 campuses serving the indigent pediatric population of the greater Dallas metropolitan area and performs an average of 40,000 anesthetic encounters per year. METHODS: We examined the data from a difficult airway database from a major tertiary care pediatric hospital to determine patient factors that led to airway improvement over time. Patients enrolled in the registry from November 2006 to October 2019 due to difficulties with intubation or mask ventilation were studied through statistical analysis. RESULTS: A total of 579 patients were identified. The Kaplan-Meier estimate of the 5-year deactivation rate was 14%. The most common reason for deactivation in our cohort was resolution of the difficult airway as defined by direct laryngoscopy Cormack and Lehane grade I or IIa/IIb, easy mask ventilation or laryngeal mask placement, or resolution of subglottic stenosis. CONCLUSION: Advancing age and male sex at the time of enrollment were the most important predictors of an airway remaining difficult.

A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry.

BACKGROUND: The design of a videolaryngoscope blade may affect its efficacy. We classified videolaryngoscope blades as standard and non-standard shapes to compare their efficacy performing tracheal intubation in children enrolled in the Paediatric Difficult Intubation Registry. METHODS: Cases entered in the Registry from March 2017 to January 2020 were analysed. We compared the success rates of initial and eventual tracheal intubation, complications, and technical difficulties between the two groups and by weight stratification. RESULTS: Videolaryngoscopy was used in 1313 patients. Standard and non-standard blades were used in 529 and 740 patients, respectively. Both types were used in 44 patients. In children weighing <5 kg, standard blades had significantly greater success than non-standard blades at initial (51% vs 26%, P=0.002) and eventual (81% vs 58%, P=0.002) attempts at tracheal intubation. In multivariable logistic regression analysis, standard blades had 3-fold greater odds of success at initial tracheal intubations compared with non-standard blades (adjusted odds ratio 3.0, 95% confidence interval): 1.32-6.86, P=0.0009). Standard blades had 2.6-fold greater odds of success at eventual tracheal intubation compared with non-standard blades in children weighing <5 kg (adjusted odds ratio 2.6, 95% confidence interval: 1.08-6.25, P=0.033). There was no significant difference found in children weighing ≥5 kg. CONCLUSIONS: In infants weighing <5 kg, videolaryngoscopy with standard blades was associated with a significantly greater success rate than videolaryngoscopy with non-standard blades. Videolaryngoscopy with a standard blade is a sensible choice for tracheal intubation in children who weigh <5 kg.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial.

BACKGROUND: Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy. METHODS: In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432. FINDINGS: Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028). INTERPRETATION: Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications. FUNDING: Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

Anesthetic implications of a pediatric patient with stiff skin syndrome: A case report.

Stiff skin syndrome is a rare genetic disorder that is present in infancy or early childhood. It is characterized by hard, inflexible skin and limited joint mobility making anesthetic management of these patients challenging. Their limited neck flexibility and chest wall rigidity make intubation and mask ventilation difficult. Intraoperative positioning can be challenging due to joint contractures and potential entrapment peripheral neuropathy. Even though peripheral intravenous access can be relatively easy, central venous cannulation may be problematic due to the hard skin overlying the entry sites. Our case report details the anesthetic management and considerations of a pediatric patient with stiff skin syndrome.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Characterization of upper airway obstruction using cine MRI in children with residual obstructive sleep apnea after adenotonsillectomy.

OBJECTIVES/BACKGROUND: Tonsillectomy and adenoidectomy (T&A) lead to resolution of obstructive sleep apnea (OSA) in most children. However, OSA persists in about 25-40% of children. Cinematic magnetic resonance imaging (cine MRI) can aid the management of persistent OSA by localizing airway obstruction. We describe our experience in implementing and optimizing a cine MRI protocol by using a 3 Tesla MRI scanner, and the use of dexmedetomidine for sedation to improve reproducibility, safety, and diagnostic accuracy. PATIENTS/METHODS: Patients aged 3-18 years who underwent cine MRI for the evaluation of persistent OSA after T&A and failed positive airway pressure (PAP) therapy were included. Clinical data and the apnea-hyponea index were compared with quantitative and qualitative estimates of airway obstruction from imaging sequences. RESULTS: A total of 36 children were included with a mean age of 9.6 ± 4.6 (SD) years with 40% over 12 years of age. Two-thirds of them were boys. Seventeen out of 36 children (47%) had Down syndrome. Single site and multilevel obstruction were identified in 21 of 36 patients (58%) and in 12 of 36 patients (33%), respectively. All cine MRIs were performed without complications. Multiple regression analysis demonstrated that a combination of the minimum airway diameter and body mass index z-score best predicted OSA severity (P = 0.002). CONCLUSIONS: Cine MRI is a sensitive, safe, and noninvasive modality for visualizing upper airway obstruction in children with persistent OSA after T&A. Accurate identification of obstruction can assist in surgical planning in children who fail PAP therapy.

Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

BACKGROUND: The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. METHODS: Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. RESULTS: Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. CONCLUSIONS: In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

Oxygen Reserve Index: A Novel Noninvasive Measure of Oxygen Reserve--A Pilot Study.

BACKGROUND: Pulse oximetry provides no indication of downward trends in PaO2 until saturation begins to decrease. The Oxygen Reserve Index (ORI) is a novel pulse oximeter-based nondimensional index that ranges from 1 to 0 as PaO2 decreases from about 200 to 80 mmHg and is measured by optically detecting changes in SvO2 after SaO2 saturates to the maximum. The authors tested the hypothesis that the ORI provides a clinically important warning of impending desaturation in pediatric patients during induction of anesthesia. METHODS: After preoxygenation, anesthesia induction, and tracheal intubation, the anesthesia circuit was disconnected and oxygen saturation was allowed to decrease to 90% before ventilation recommenced. The ORI and SpO2 values were recorded from a Masimo Pulse Co-Oximeter Sensor at the beginning of apnea, beginning and end of intubation, beginning and end of the ORI alarm, and 2 min after reoxygenation. RESULTS: Data from 25 healthy children, aged 7.6 ± 4.6 yr, were included in the analysis. During apnea, the ORI slowly and progressively decreased over a mean of 5.9 ± 3.1 min from 0.73 ± 0.16 at the beginning of apnea to 0.37 ± 0.11. SpO2 remained 100% throughout this initial period. Concurrently with alarm activation, the ORI began to decrease rapidly, and in median of 31.5 s (interquartile range, 19 to 34.3 s), saturation decreased to 98%. CONCLUSIONS: In this pilot study, the ORI detected impending desaturation in median of 31.5 s (interquartile range, 19-34.3 s) before noticeable changes in SpO2 occurred. This represents a clinically important warning time, which might give clinicians time for corrective actions.

Detection, frequency and prediction of problems in the use of the proseal laryngeal mask airway in children.

OBJECTIVES: Our objective was to assess the use of several tests of ProSeal LMA (PLMA) position and function that had been previously published but not studied in the pediatric population in a wide variety of clinical cases. BACKGROUND: The PLMA is widely used in pediatric anesthesia practice but complication rates have only been studied in small series while tests of function suggested for adults have not been studied at all. METHODS: We prospectively collected data, after placement of the PLMA by the digital method, on depth of insertion (DOI), 'suprasternal notch' test, 'chest pressure test', leak pressure, maximum minute ventilation (MMV), resting minute ventilation (RMV), success rate of insertion and success rate of passage of a gastric tube. Perioperative complication rates were recorded. RESULTS: A total of 222 cases were analyzed, 47 were laparoscopic or open abdomen, 15 nonsupine. Ages were 2 months to 20 years and weight 5.4-116 kg. Two hundred seven (91%) were placed successfully at first attempt and 100% at third attempt. One hundred fifty-four of 156 (99%) gastric tubes were placed successfully. Four patients had signs of inadequate ventilation. All of these had MMV/RMV ratios <2. A total of nine had MMV/RMV ratio <2. Eight had DOI score < or =2. CONCLUSIONS: The PLMA can be used in a large variety of cases with a high degree of success. Clinical tests described for adults, such as MMV/RMV ratio and DOI are also associated with complications in the pediatric population.

Use of the ProSeal laryngeal mask airway in an infant with a repaired H-type tracheoesophageal fistula and tracheomalacia.

The ProSeal laryngeal mask airway (PLMA) is a relatively new airway device with design features that improve the quality of positive pressure ventilation (PPV) and may decrease the risk of gastric aspiration. We describe the use of this device for the anesthesia management of an infant with an esophagocutaneous fistula following repair of an H-type tracheoesophageal fistula and tracheomalacia, in which avoidance of tracheal intubation was desired. This case report demonstrates that the PLMA may be a useful and practical alternative to tracheal intubation in an infant with a tenuous airway.