Awake Supraglottic Airway Placement in Pediatric Patients
Myron Yaster MD, Melissa Brooks Peterson MD, Jamie Peyton MD, and Francis Veyckemans MD
Before beginning today’s PAAD by Longacre et al.1 let’s take a minute and celebrate the Pediatric Difficult Intubation (PeDI) Registry group, founded as a special interest group of the Society for Pediatric Anesthesia. It is an international multicenter organization dedicated to assessing, understanding and improving the outcomes of children with Difficult Direct Laryngoscopy (DDL) to facilitate benchmarking, quality improvement and research. The objectives of the group are (1) to provide site specific and aggregate data back to sites on DDL events and (2) to augment local quality improvement efforts and (3) to facilitate research studies related to DDL Today’s article is yet another in a long list of articles that have transformed the practice of pediatric anesthesia.2-9
We’ve all been in the hotseat when a patient presents with a known difficult airway and when I saw the title of today’s article, I wondered “what are they smoking”? “An awake insertion of a supraglottic airway in infants and children”? And in patients in whom the production of laryngospasm could be catastrophic? And yet, the PeDIR has the DATA to show outcomes, either the technique’s effectiveness or its failure. I’ve asked the PAADs airway experts to weigh in, some of whom are actively involved in the PeDIR and authors of this article. Myron Yaster MD
Original article
Longacre M, Park RS, Staffa SJ, Rowland MJ, Meserve J, Lord C, Templeton TW, Garcia-Marcinkiewicz AG, Peyton JM, Fiadjoe JE, Kovatsis PG, Stein ML; PeDI Collaborative Investigators. Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI). Anesth Analg. 2025 Feb 1;140(2):310-316. doi: 10.1213/ANE.0000000000006959. Epub 2024 Oct 24. PMID: 39446662.
“Difficult airway management in children has unique considerations including pathophysiology, technique, and equipment size. Difficult intubation is associated with high morbidity in children, including hypoxia and cardiac arrest.2 Adding to these challenges, awake intubation, the gold standard in adult airway management, may be impractical or impossible in children and neonates.”1 “Supraglottic airways (SGAs) have become an essential part of airway management, including the management of difficult airways. SGAs can rescue failed mask ventilation or failed endotracheal intubation by allowing oxygenation and ventilation while providing a conduit for intubation. SGAs can also be placed in awake patients for difficult airway management. In adults, awake SGA placement allows clinicians to confirm the ability to ventilate before the induction of general anesthesia in patients for whom ventilation is anticipated to be difficult.”1 The authors wondered if awake supraglottic airway placement in pediatric patients with difficult airways leads to successful ventilation and subsequent intubation?
Using the registry “93 unique patients (of the 8,061 patients in the registry) had 95 encounters in which an SGA was placed in an awake child before planned tracheal intubation (=1.1% of cases). Thus it was infrequently performed but was mostly effective and resulted in adequate ventilation and successful subsequent intubation in neonates as well as older, larger patients with few complications associated with device placement. Clinicians placed SGAs in children without any sedative medications in 65% (62/95) of cases in this cohort with 81% (50/62) incidence of adequate ventilation. “Despite these successes, awake SGA placement was not failproof. There were 14 instances of inadequate or impossible ventilation via the SGA and a 36% incidence of hypoxia in encounters with inadequate or impossible ventilation via the SGA. As successful oxygenation and ventilation are not guaranteed, clinicians must be prepared with alternative plans to successfully manage these patients.”1
“Previous work from the PeDI Registry has shown that SGA placement should be considered to improve ventilation in children with difficult mask ventilation.9 In this cohort, we found that inadequate ventilation via the SGA could also often be rescued with mask ventilation, and that patients with difficult or impossible facemask ventilation could frequently be ventilated via an SGA. These findings along with the low first-attempt intubation success rate reinforce the need for clinicians to maintain expertise in a wide variety of techniques for airway management and a willingness to change techniques when necessary.”
Finally, although most patients were not sedated, approximately a third were, either with light (n=25) or deep sedation. Based on the findings of this study, inserting a SGA in an awake or sedated child at risk for difficult intubation and or ventilation could be added as an option in fig 2 and 4 of the 2022 ASA recommendations for difficult airway management.
Again we applaud the PeDIR for its continuing work in this area. And a final note: I (JP) found this an interesting paper to work on as this is a technique that is rather rare, but one that I was taught in my fellowship at Boston Children’s Hospital and we use often with neonates with anatomical abnormalities such as Robin Sequence where we are concerned both mask ventilation and intubation will be challenging. We use topical lidocaine to help patients tolerate insertion of the SGA, with sedation at the discretion of the attending anesthesiologist. Personally, I do not sedate them until the SGA is in place, and as an observation (one that is borne out by the data in this paper) most of the patients tolerate placement well, their airway obstruction is relieved, and we can then safely anesthetise them with an unobstructed airway.
Another part to this paper that I (JP) think is valuable is the description of the case where things did not go as planned. This is where I have to confess that it was a case I was involved in that is now immortalized in print (“The single patient with inadequate ventilation via SGA and facemask was a 19-day-old 3-kg neonate with Robin sequence and significant airway obstruction scheduled for mandibular distraction….”). My colleague in Boston (and all our PeDIR work) Ray Park, and I continue to have nightmares about this case. It is an illustration both of what can go wrong and then how to safely deal with a lost airway. We went through a systematic process of changing technique, equipment, and provider, focusing on oxygenation, avoiding task fixation and making the decision to abandon attempts at airway management before we were unable to do so. We were glad we could just about oxygenate once we reversed the muscle relaxation, and despite some brief periods of hypoxia there were no episodes of bradycardia or need for CPR. We rapidly reached a point where we felt further attempts could cause significant airway swelling so made the decision to stop and wake the patient up (which can be a difficult decision to make). Returning to the OR 3 days later for an awake flexible bronchoscopic nasal intubation worked well, and while it could be argued that this could have been done sooner given the situation we were in, after the multiple attempts at airway management I think we maintained situational awareness and made the right choice at that time by not aggressively pursuing intubation and potentially making things worse.
Send your thoughts and comments to Myron who will post in a Friday reader response
References
1. Longacre M, Park RS, Staffa SJ, Rowland MJ, Meserve J, Lord C, Templeton TW, Garcia-Marcinkiewicz AG, Peyton JM, Fiadjoe JE, Kovatsis PG, Stein ML; PeDI Collaborative Investigators. Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI). Anesth Analg. 2025 Feb 1;140(2):310-316. doi: 10.1213/ANE.0000000000006959. Epub 2024 Oct 24. PMID: 39446662.
2. Longacre M, Park RS, Staffa SJ, Rowland MJ, Meserve J, Lord C, Templeton TW, Garcia-Marcinkiewicz AG, Peyton JM, Fiadjoe JE, Kovatsis PG, Stein ML; PeDI Collaborative Investigators. Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI). Anesth Analg. 2025 Feb 1;140(2):310-316. doi: 10.1213/ANE.0000000000006959. Epub 2024 Oct 24. PMID: 39446662.
3. Burjek NE, Nishisaki A, Fiadjoe JE, Adams HD, Peeples KN, Raman VT, Olomu PN, Kovatsis PG, Jagannathan N, Hunyady A, Bosenberg A, Tham S, Low D, Hopkins P, Glover C, Olutoye O, Szmuk P, McCloskey J, Dalesio N, Koka R, Greenberg R, Watkins S, Patel V, Reynolds P, Matuszczak M, Jain R, Khalil S, Polaner D, Zieg J, Szolnoki J, Sathyamoorthy K, Taicher B, Riveros Perez NR, Bhattacharya S, Bhalla T, Stricker P, Lockman J, Galvez J, Rehman M, Von Ungern-Sternberg B, Sommerfield D, Soneru C, Chiao F, Richtsfeld M, Belani K, Sarmiento L, Mireles S, Bilen Rosas G, Park R, Peyton J; PeDI Collaborative Investigators. Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology. 2017 Sep;127(3):432-440. doi: 10.1097/ALN.0000000000001758. PMID: 28650415.
4. Park R, Peyton JM, Fiadjoe JE, Hunyady AI, Kimball T, Zurakowski D, Kovatsis PG; PeDI Collaborative Investigators; PeDI collaborative investigators. The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. Br J Anaesth. 2017 Nov 1;119(5):984-992. doi: 10.1093/bja/aex344. PMID: 29028952.
5. Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, von Ungern-Sternberg BS. A framework for the management of the pediatric airway. Paediatr Anaesth. 2019 Oct;29(10):985-992. doi: 10.1111/pan.13716. Epub 2019 Sep 2. PMID: 31402534.
6. Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, Patel V, Jagannathan N, Burjek N, Mensinger JL, Zhang B, Peeples KN, Kovatsis PG, Fiadjoe JE; PeDI Collaborative. A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesth Analg. 2020 Aug;131(2):469-479. doi: 10.1213/ANE.0000000000004393. PMID: 31567318.
7. Peyton J, Park R, Staffa SJ, Sabato S, Templeton TW, Stein ML, Garcia-Marcinkiewicz AG, Kiss E, Fiadjoe JE, von Ungern-Sternberg B, Chiao F, Olomu P, Zurakowski D, Kovatsis PG; PeDI Collaborative Investigators. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. Br J Anaesth. 2021 Jan;126(1):331-339. doi: 10.1016/j.bja.2020.08.010. Epub 2020 Sep 17. PMID: 32950248.
8. Flynn SG, Stein ML, Fiadjoe JE. Supraglottic Airways, Tennis, and Neonatal Resuscitation. Pediatrics. 2022 Sep 1;150(3):e2022057567. doi: 10.1542/peds.2022-057567. PMID: 35948629.
9.Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW; PeDI Collaborative. Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth. 2023 Jul;131(1):178-187. doi: 10.1016/j.bja.2023.02.035. Epub 2023 Apr 17. PMID: 37076335.