Is there anything more fundamental to anesthesia practice than airway management? I don’t think so, thus, whenever I see an article on PEDIATRIC airway management it goes to the top of the pile for a Pediatric Anesthesia Article of the Day. For those of you who teach these essential skills, today’s PAAD may be of great value to you as a resource for teaching your beginner students. It is heavily referenced and has beautiful and very clear figures which can be downloaded as Powerpoint slides.(see below) It was published in the July issue of ASA Monitor by Dr. Aman Kalra of the Tufts University School of Medicine. Because the ASA Monitor goes to all members of ASA it will reach a very diverse group of practitioners and may appear to be over-simplified for many of you who practice pediatric anesthesia on a daily basis. Fear not though. It contains many pearls that we’ll discuss below. I’ve asked Mel Brooks who is one of the PAAD’s airway gurus to co-write this with me. Myron Yaster MD
Original article
Aman Kalra, MD. Pediatric Airway Management: Unique Perspectives and New Thoughts. ASA Monitor July 2022, Vol. 86, 22–24. https://doi.org/10.1097/01.ASM.0000842056.25323.45
Dr. Kalra provides an overview, really a primer, on pediatric airway management based on his extensive experience. The article is divided into preoperative assessment and identifying red flags, positioning the patient’s head and upper body, how to maintain upper airway patency, and finally a section on intubation equipment and techniques.
The take-aways from this article are “yes, agree… yes, we do this every day… yes, obviously” – I (MBP) found this article to be elementary. Honestly, on first read I called Myron and asked him why on earth he picked it for the PAAD! He told me a couple good reasons why, which we will highlight below. So here are the upsides: the potential of this article is to serve as a quick reference for your beginner anesthesiology/airway students. Because nearly every hospital in the country has “visiting learners” who come to the ORs for airway skills – this type of article can serve as a Cliff Notes for pediatric airway management skills for those students. Examples of these learners include Emergency Medical Technicians, transport and flight RNs and RTs, Pediatricians, ICU fellows, acute care nurse practitioner students, etc. All of these learners need basic pediatric airway skills and a common vocabulary. This article can easily serve as a basic text that they should read and keep for future reference. The other set of people who may benefit from this article are generalists who see a pediatric patient only occasionally.
Dr. Kalra’s review is well referenced with many classic papers. Unfortunately there are some recent papers about advances in pediatric airway management that were not included. First, and perhaps most importantly is the utility and importance of supplemental passive oxygenation via either low flow or high flow nasal cannula during intubation. Although always a good idea, the use of supplementary oxygen is particularly important in the very young or when a difficult airway based on history and physical exam is expected.1, 2 Second, there is a growing body of evidence that the FIRST intubation attempt in the newborn and in patients with known or suspected difficult airways may best be performed with a videolaryngoscope.3-5 Time will tell if this technique becomes standard or recommended. Lastly, the continuous publications coming out of the Pediatric Difficult Intubation Registry (PeDIR) – and even the existence of such a workgroup – deserve mention and attention in this review.3, 4, 6
I (Myron) agree with everything Mel detailed above but want to share that the major take-away I identified for this article are the figures. I was struck by the quality as well as share-ability of the figures in this article. I’ve included in the PAAD figures which I think are great and are better than can be found in many other sources. So, use these images if they will help you teach, lecture, or support the good work you do everyday.
References
1. Hsu G, von Ungern-Sternberg BS, Engelhardt T. Pediatric airway management. Current opinion in anaesthesiology. Jun 1 2021;34(3):276-283. doi:10.1097/aco.0000000000000993
2. Else SDN, Kovatsis PG. A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures. Anesthesia and analgesia. Apr 2020;130(4):831-840. doi:10.1213/ane.0000000000004403
3. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, et al. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet (London, England). Dec 12 2020;396(10266):1905-1913. doi:10.1016/s0140-6736(20)32532-0
4. Peyton J, Park R, Staffa SJ, et al. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. British journal of anaesthesia. Jan 2021;126(1):331-339. doi:10.1016/j.bja.2020.08.010
5. Park R, Peyton JM, Fiadjoe JE, et al. The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. British journal of anaesthesia. Nov 1 2017;119(5):984-992. doi:10.1093/bja/aex344
6. Matava CT, Kovatsis PG, Summers JL, et al. 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. Anesthesia and analgesia. Apr 13 2020;doi:10.1213/ane.0000000000004872