Official American Thoracic Society technical standards: flexible airway endoscopy in children.

BACKGROUND: Flexible airway endoscopy (FAE) is an accepted and frequently performed procedure in the evaluation of children with known or suspected airway and lung parenchymal disorders. However, published technical standards on how to perform FAE in children are lacking. METHODS: The American Thoracic Society (ATS) approved the formation of a multidisciplinary committee to delineate technical standards for performing FAE in children. The committee completed a pragmatic synthesis of the evidence and used the evidence synthesis to answer clinically relevant questions. RESULTS: There is a paucity of randomized controlled trials in pediatric FAE. The committee developed recommendations based predominantly on the collective clinical experience of our committee members highlighting the importance of FAE-specific airway management techniques and anesthesia, establishing suggested competencies for the bronchoscopist in training, and defining areas deserving further investigation. CONCLUSIONS: These ATS-sponsored technical standards describe the equipment, personnel, competencies, and special procedures associated with FAE in children.

Emergent airway management in the labor and delivery suite.

INTRODUCTION: Congenital airway obstruction is of varied etiology and uncommonly encountered. Prenatal care and imaging have enhanced detection of these abnormalities and allow for multi-disciplinary care planning for airway management at delivery. Despite the availability and advances in prenatal imaging, unanticipated airway obstruction may not be identified until the time of delivery. METHODS: Case series. RESULTS: Four airway emergencies were encountered in the labor and delivery suite over an eight-month period. Clinical history is correlated with autopsy findings. Congenital upper airway and laryngotracheal anomalies are reviewed. Recommendations to improve timely and efficient airway management in the labor and delivery suite are discussed and a protocol for a multi-disciplinary neonatal emergency airway response team is offered for consideration. CONCLUSIONS: The development and implementation of a multi-disciplinary emergency newborn airway protocol is both realistic and feasible. While it did not improve survivability in our small group, it did reduce response time. It, or a protocol like it, is recommended for institutions caring for high-risk pregnancies and with Neonatal Intensive Care Units with high acuity patients.

Bronchoscopy and airway management in patients with mucopolysaccharidoses (MPS).

INTRODUCTION: Mucopolysaccharidoses (MPS) are a group of lysosomal storage disorders characterized by tissue deposition of glycosaminoglycans (GAG). Their musculoskeletal abnormalities and the GAG storage in the airway result in increased risk for patients undergoing anesthesia. This study evaluates a multi-disciplinary airway management approach and reports upper and lower airway findings of flexible bronchoscopy performed during these procedures. METHODS: This is a retrospective study over 10 years evaluating approaches to and outcomes of airway management and bronchoscopic findings in this patient group. RESULTS: Thirty-one patients underwent a total of 105 anesthetic events of which 74 involved multiple surgical services. The majority of patients were either MPS I (n = 9) or MPS II (n = 19). The median age was 8.6 years (range 1.1-24 years). Airway management by anesthesiologists alone occurred in 31 cases including natural airway (n = 7), perilaryngeal airway (n = 7), oral or nasal intubation (n = 7) or tracheostomy (n = 6) and emergent fiberoptic intubation in four cases. In 74 of the procedures, flexible bronchoscopy was performed which included fiberoptic intubation in 22 cases. Post-operative complications occurred in eight cases mostly when prolonged airway instrumentation had occurred. The most frequent findings on bronchoscopy were GAG deposits/adenoid hypertrophy in 72%, laryngomalacia in 31% and lower airway deposits and/or tracheobronchomalacia in 46% of procedures. Deposits of GAG were seen in patients as young as 4 years of age. CONCLUSION: Our experience demonstrates that a multidisciplinary approach and combined surgeries in MPS provides for safe airway management and allows diagnostic assessments for further patient care without added risks. Significant, multi-factorial airway compromise may occur already in early childhood including upper and lower airway GAG deposits.