Pediatric Airway Management

A 3-year-old child with recurrent croup presents for adenotonsillectomy. The child has a history of difficult intubation during previous anesthesia. Parents report occasional stridor during sleep and upper respiratory infections.

This pediatric scenario presents a significant and multifaceted airway challenge. The convergence of a known difficult airway, a history of reactive airway disease (croup), and a procedure that itself causes airway edema (adenotonsillectomy) makes this a high-risk case that demands meticulous planning and execution.

Here is a detailed breakdown of the peri-operative anesthetic management for this 3-year-old child.

Peri-Operative Anesthetic Plan

Patient Summary: 3-year-old child, scheduled for Adenotonsillectomy. Significant history includes recurrent croup, a documented difficult intubation during a previous anesthetic, and occasional nocturnal stridor, suggesting potential obstructive sleep apnea (OSA).

Core Principles:

  1. Safety First: The primary goal is to maintain oxygenation at all times. The airway is the central focus of the entire anesthetic plan.
  2. Preparation is Paramount: Anticipate failure and have multiple, immediately available backup plans. This is not a case for improvisation.
  3. Preserve Spontaneous Ventilation: Until the airway is secured and lung ventilation confirmed, maintaining the patient's own respiratory drive is the safest option.
  4. Minimize Airway Trauma and Irritation: Every manipulation, from mask ventilation to suctioning, must be gentle to prevent iatrogenic edema on top of an already compromised airway.
  5. Proactive Management of Edema: Assume significant post-operative airway edema will occur and treat it pre-emptively.

I. Pre-Anesthetic Check-up & Optimization

This phase is diagnostic and strategic. The information gathered here will dictate the entire intra-operative approach.

A. Detailed History and Physical Examination:

  • Airway History (The Most Critical Information):
    • Obtain Previous Anesthetic Records: This is non-negotiable. We need to know exactly what happened. What was the Cormack-Lehane view? What laryngoscope blades were used (e.g., Miller, Macintosh)? What size and type of endotracheal tube (ETT) was placed (cuffed vs. uncuffed)? Was a supraglottic airway (SGA) like an LMA used? Was a fiberoptic bronchoscope required? Were there any desaturation events or airway trauma?
    • Parental Interview: Ask the parents for their recollection of the event. Was the child in the hospital overnight? Did they have a sore voice or croup afterward?
  • Croup History:
    • How many episodes? How recent was the last one? Was it severe enough to require steroids, nebulized epinephrine, or hospitalization? This gives us an idea of how "reactive" the subglottic area is. The surgery should ideally be scheduled well after any recent URI or croup episode (e.g., >4-6 weeks).
  • Stridor and OSA History:
    • Characterize the nocturnal stridor. Is it constant or intermittent? Are there witnessed apneas, choking episodes, or significant arousals? Does the child have daytime somnolence or behavioral issues? Severe OSA increases sensitivity to opioids and sedatives and heightens the risk of post-operative airway obstruction.
  • Upper Respiratory Infection (URI) History:
    • Is the child currently symptomatic (runny nose, cough, fever)? An active URI is a strong relative contraindication for elective airway surgery in a child with this history, as it dramatically increases the risk of severe laryngospasm and postoperative croup. The decision to proceed vs. postpone must be made in conjunction with the parents and surgeon.
  • Physical Examination:
    • Airway Exam: Assess mouth opening, dentition, size of the tongue relative to the oral cavity (Mallampati is less reliable but still noted), and presence of micrognathia or a short neck. Look for any anatomical clues that might explain the previous difficulty.
    • Cardiopulmonary Exam: Listen to the chest for any wheezes or crackles, which might indicate active bronchospasm or lower airway pathology.

B. Investigations:

  • Review of Records: As mentioned, this is the most important "investigation."
  • Imaging (if indicated): A lateral neck X-ray could be considered if there is suspicion of a subglottic stenosis or other anatomical lesion, but the history of croup makes inflammatory edema more likely.

C. Multidisciplinary Discussion and Consent:

  • Surgical Discussion: Have a detailed conversation with the ENT surgeon. Inform them of the plan and the high risk of airway complications. Ensure they are immediately available and prepared for an emergency front-of-neck access (FONA), i.e., a surgical tracheostomy, if it becomes necessary.
  • Informed Consent: Have a very frank and detailed discussion with the parents/guardians. Explain the risks clearly:
    • Failed intubation.
    • Inability to ventilate (Can't Intubate, Can't Oxygenate - CICO scenario).
    • Need for an emergency surgical airway (tracheostomy).
    • Severe postoperative airway edema requiring reintubation and ICU admission.
    • Postoperative bleeding and the risk of aspiration.
    • The possibility of canceling the case on the day of surgery if the airway appears too risky.

II. Intra-Operative Management

A. Preparation and Equipment:

  • Team: This case must be managed by a senior pediatric anesthesiologist with extensive experience in difficult pediatric airways. An experienced assistant is also required.
  • Equipment Check (The Difficult Airway Trolley):
    • Laryngoscopes: Multiple sizes of Miller (straight) and Macintosh (curved) blades. A video laryngoscope (e.g., Glidescope, C-Mac) is essential.
    • Endotracheal Tubes (ETTs): A full range of sizes, both cuffed and uncuffed. Have tubes 0.5mm smaller than expected for age readily available.
    • Supraglottic Airways (SGAs): Multiple sizes of LMAs (e.g., Ambu Aura-i, LMA Supreme) that can be used as a rescue device or a conduit for intubation.
    • Fiberoptic Bronchoscope: A pediatric bronchoscope with a functioning light source and suction channel, checked and ready.
    • Airway Exchange Catheters: e.g., a Cook catheter.
    • Emergency Front-of-Neck Access (FONA) Kit: A pediatric cricothyrotomy/transtracheal jet ventilation kit and a surgical tracheostomy set, which should be with the ENT team.
    • Suction: Two functioning suction devices with Yankauer catheters.
    • Pharmacology: Have all necessary drugs drawn up, including atropine, propofol, sevoflurane, succinylcholine, rocuronium, and nebulized racemic epinephrine.

B. Anesthetic Technique:

  • The Plan: A Spontaneous Ventilation Inhalational Induction is the safest primary strategy. This allows for assessment of the airway while the child continues to breathe. If the airway cannot be secured, the anesthetic can be lightened and the child allowed to wake up.
  • Induction:
    1. Apply standard monitors (ECG, NIBP, SpO2). Pre-oxygenate with 100% O2 for several minutes.
    2. A gentle, calm inhalational induction with Sevoflurane in 100% oxygen is performed. Avoid struggling, as it can worsen airway edema.
    3. Once an adequate depth of anesthesia is achieved, gently perform laryngoscopy.
  • Securing the Airway (A Tiered Approach):
    • Plan A (Direct Laryngoscopy): Attempt direct laryngoscopy with the blade that worked best previously (or a video laryngoscope as the first choice). If a grade 1 or 2 view is obtained, a small dose of a short-acting muscle relaxant (e.g., rocuronium) can be given to facilitate intubation with an appropriately sized cuffed ETT.
    • Plan B (Video Laryngoscope / SGA): If direct laryngoscopy is poor (Grade 3/4), immediately switch to a video laryngoscope. If still unsuccessful, place an appropriately sized SGA to maintain ventilation.
    • Plan C (Fiberoptic Intubation): Once ventilation is confirmed via the SGA, perform a fiberoptic intubation through the SGA. This is a controlled and effective technique. The SGA can then be removed over an airway exchange catheter.
    • Plan D (Awake Fiberoptic Intubation): This is rarely feasible in a 3-year-old but might be considered if all other options are deemed too risky and the child is extremely cooperative.
    • Plan E (CICO - Front of Neck Access): If ventilation via a face mask or SGA becomes impossible and oxygenation is failing, this is a CICO emergency. Call for the ENT surgeon immediately and proceed with emergency transtracheal jet ventilation or a surgical tracheostomy.

C. Maintenance and Emergence:

  • Maintenance: A Total Intravenous Anesthesia (TIVA) with Propofol and Remifentanil is an excellent choice to avoid airway irritation from volatile gases. The surgeon can perform local anesthetic infiltration to reduce opioid requirements.
  • Intra-Operative Steroids: Administer IV Dexamethasone (0.5-1 mg/kg, max 10mg) at the start of the surgery to proactively reduce airway edema.
  • Emergence & Extubation: This is a period of extreme danger.
    • Deep Extubation is ABSOLUTELY CONTRAINDICATED in this child.
    • The goal is a fully awake, smooth extubation.
    • Ensure the child is completely reversed from any muscle relaxant.
    • Thoroughly but gently suction the oropharynx under direct vision.
    • Extubate only when the child is awake, opening their eyes on command, and has strong, purposeful movements.
    • Have the child sit up or be placed in the lateral position immediately after extubation.
    • Have nebulized racemic epinephrine and a source of positive pressure ventilation (e.g., CPAP mask) immediately available at the bedside.

III. Post-Operative Management

A. Location and Monitoring:

  • This child should be admitted to a High Dependency Unit (HDU) or Pediatric Intensive Care Unit (PICU) for overnight observation. A standard Phase I PACU is not equipped for the level of monitoring this child requires.
  • Monitoring: Continuous pulse oximetry with a good waveform, continuous capnography (if available) to detect early obstruction, and frequent nursing observations (every 5-15 minutes initially). Use a standardized "stridor score" to track any airway compromise.

B. Airway Management:

  • Humidified Air/Oxygen: To soothe the airway and reduce secretions.
  • Positioning: Keep the child in a position of comfort, usually sitting up or with the head of the bed elevated.
  • Rescue Medications: Have a clear, written protocol for managing post-operative croup/stridor:
    1. Racemic Epinephrine nebulization.
    2. Additional doses of Dexamethasone.
    3. If stridor is severe or worsening, consider reintubation. This should be done in a controlled manner by the senior anesthesiologist, potentially over a fiberoptic bronchoscope or airway exchange catheter.

C. Pain Management:

  • Multimodal Analgesia is Essential to minimize opioid use.
    • Scheduled IV Acetaminophen.
    • IV NSAIDs (e.g., Ibuprofen) if not contraindicated.
    • If opioids are required (e.g., Morphine or Oxycodone), use them with extreme caution, at low doses, and with close monitoring for respiratory depression.

D. Discharge Planning:

  • The child must be completely stable, pain-free on oral analgesics, and have no signs of airway compromise (no stridor at rest, comfortable breathing on room air) for a significant observation period before being considered for discharge to the general ward or home. This may require a longer stay than a typical T&A patient.

Conclusion:

This case represents a perfect storm of pediatric airway risks. Success hinges on a conservative, safety-first approach. By prioritizing spontaneous ventilation, having a well-rehearsed, tiered plan for airway management, and anticipating severe post-operative edema, we can navigate this high-stakes scenario and ensure the child's safety. The mantra is: Prepare, Plan, and Protect the Airway.

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