J.

Scott Lowry, MD, FACEP

Midlevel Medical Director
Southwest Emergency Associates
Dept. of Emergency Medicine
Tucson Medical Center

Objectives
1. Be able to evaluate a pediatric airway.

2. Know how to prepare for a difficult

airway/intubation

3. Be ready to manage a difficult or failed pediatric

airway

4. Be aware of difficult airway adjuncts and devices

Back to the ABCs

A Airway
B Breathing
C Circulation
 Evaluating the Patients Airway
Listen
A talking patient gives you a lot of information
Talking demonstrates their airway is currently open, and
the quality of the voice can often warn you of impending
airway problems or difficulty, so listen to your patients!
Hoarse voice
Hot Potato voice
Stridor
Anatomic stridor, foreign body, inflammation

Evaluating the Patients Airway

Listen
Pediatric patients are not always verbal, and in the
emergency setting, are often NOT verbal, whether due
to their medical condition, or because of their concern
or fear of the situation.
In the case of the non-verbal patient it is of particular
importance to listen closely to their breathing and
observe the use of accessory musculature.

Evaluating the Patients Airway

Look
Look at your patients face
Any anatomical problems/deformities visible
Trauma to nose, mouth, neck blunt or penetrating
Soot in or around nose or mouth
Singed eyebrows or nasal hair
Facial swelling
Look in their mouths
Soot in the mouth or upper airway
Black or bloody expectorant
Foreign bodies
Tongue or airway swelling
 First Step for Controlling an Airway
Positioning
Sniffing Position if no C-Spine concerns
Remember a more neutral position for neonates
Jaw thrust
Jaw lift
Jaw grab
Jaw Protrusion is key
Again, check for foreign bodies

ASSESS FOR DIFFICULTY TO VENTILATE

The Five Predictors of difficult bag and mask ventilation and
Oxygenation, can be summarized in the word OBESE or
MOANS

OBESE MOANS
Obese (BMI > 26 kg/m2) Mask seal (beard, etc.)
Bearded Obese (BMI or swelling)
Elderly (>55 yo) Aged (> 55yo)
Snorers No teeth
Edentulous Snores or Stiff (sleep
apnea, C-spine issues)
 Bag Valve Mask, Bagging a patient, (BVM)
Proper BVM is THE MOST important skill in managing an airway
Assess (OBESE or MOANS)
Good seal Most important in smaller pediatric
patients is mask size selection.
Readjust as needed, Vaseline if needed
One handed or Two handed positioning on mask
Position the patient appropriately, reposition as
needed

Bag Valve Mask, Bagging a patient, (BVM)

Proper BVM is THE MOST important skill in managing an airway
Oral and/or nasal airway
Adults - You havent failed BVM unless you cant bag
with an oral airway and two nasal trumpets.
Be cautious with nasal airways in younger
pediatric patients, as their mucosa can be very
fragile, creating a new airway complcation.
 Position your patient properly
Roll under the shoulders for infants
Roll under the neck or head for larger patients

Proper ventilation techniques not working?

Not oxygenating?
Re-position
Check equipment
Not working?
Re-position!
Still not working?
Time to intubate!

Airway Assessment for intubation: LEMON

Look
Overall assessment i.e. small jaw, big teeth, short neck
Evaluate 3-3-2
Mouth open 3 finger widths
Thyromental distance of 3 finger widths
Hyoid to neck-mandible junction of 2 finger widths
Mallampati Class
Obstruction
Neck Mobility
 Assessment for peds intubation: LEMON
Look
Overall assessment i.e. small jaw, big teeth, short neck
Evaluate
Mouth opening
Neck to jaw size ratio
Neck mobility
Mouth Opening
Obstruction
Neck Mobility
 Anticipating a difficult intubation:
Patils Triangle (3-3-2 rule)
Mallampati score
Cormack/Lehane system (CL or view grade)
POGO (Percentage of Glottic Opening)

Difficult extraglottic device placement: RODS

Restricted mouth opening
Obstruction
Disrupted or Distorted airway
Stiff lungs or C-Spine (limited ventilatory pressure
and fixed, flexed neck may disrupt seating of EGD)
 Difficult cricothyrotomy: SHORT
Surgery/disrupted airway anatomy
Hematoma or infection
Obese
Radiation therapy
Tumor
 Setup for intubation
Patient positioning and pre-oxygenation with NRB
BVM with O2 connected
RSI medications
Suction
Intubating tools with light source
Appropriate ETT and stylet selection
Back-up device(s)
including cricothyrotomy kit if difficult airway
suspected
End tidal CO2 detector or capnometer

RSI
What is the first drug you give for RSI?
O2!
Why?
Pre-oxegenate
But hes already 100%, how much higher do you want
him? - hopefully this is your problem
Not looking for O2 saturation, but nitrogen washout in
the lungs to build an O2 reserve!
Buy time with a lung full of O2 to burn through, while
you fiddle with the airway.
Pediatric patients desaturate much quicker than their
adult counterparts!

Cricoid Pressure
Sellick technique
Hold cricoid cartilage with thumb
and index finger and apply
sufficient pressure to dimple a
banana.

BURP
Back
Up
Right
Pressure
 Does the Sellick technique work?
Multiple studies testing which hand to use, how
many cm H2O of pressure required, direction,
instrument being used for intubation from DL to flex
fiberoptics:
Lateral displacement of esophagus relative to cricoid
cartilage negates benefits
Increased cricoid pressure increased failure rates for
successful intubation
Can help position airway for optimal intubation

Does the Sellick technique work?

Most effective for BVM
Can bag without cricoid pressure up to 15 cm H2O
without gastric inflation
With cricoid pressure, bagging up to 45 cm H2O was
achieved without gastric inflation

Gastric inflation directly correlated with passive

vomiting when paralyzed and subsequent aspiration

Pediatric Airway anatomy

Larynx is conical rather than cylindrical
Proportionately larger tongue
More anterior airway
 Epiglottis is longer, softer, floppier, and more
omega shaped.

Adult:

Epiglottis is longer, softer, floppier, and more

omega shaped.

Pediatric:
Congenital Anomalies
Laryngomalacia
Cartilaginous support structures of larynx lack integrity
Tracheomalacia
Foreshortened tracheal rings; Tracheoesophogeal septum
lacks integrity
Subglottic Stenosis
Elliptical or small cricoid ring
Laryngeal Cleft
Defect in posterior lamina of Cricoid ring
Complete Tracheal Rings
Tracheal cartilage rings forms complete rings

Tube selection
Size of tube
4 + (Age/4)
Cuffed vs. Uncuffed
Dogma states uncuffed for all pediatric patients under age 8
Studies from old tubes, old cuffs.
Conical shape of larynx provides anatomical fit however half
size too small causes air leak and potential aspiration/VAP.
Half size too big causes trauma and potentially tracheal stenosis
Pediatric ICU tube exchange rate as high as 28% for incorrect
tube size (Weiss, et al. 2007)
Take home: Use cuffed tubes. If you dont want a cuff, dont
inflate it, but its there if you need it.
Consider reducing tube size by size for cuffed tube in smaller
patients

Premedicate
Pediatric patients tend to brady down very quickly with
vagal stimulation from intubation.
Dogma used to be atropine for all children under 10,
however the bradicardic episodes are typically transient
and unlikely clinically significant
Under 1 year of age, patients are more prone to
bradycardia, and should be more strongly considered
Pretreat the younger peds patients with atropine if time
allows Highly recommended under 1 year of age
Atropine Dose: 0.02mg/kg, minimum dose 0.1mg
RSI
Consider ketamine rather than etomidate in peds, especially
the younger patients
Ketamine Dose: 1-2mg/kg
Difficult Airways are anticipated

Failed Airways are experienced

Prevalence of difficult airways

Highest in emergency settings and OB
As high as 20% of ED intubations

Incidence of failed airways

Failed intubations estimated to be between 0.5-2.5%
Highest in OB Caesarian section patients (1:280)
Failure to intubate or ventilate estimated 0.05-0.1%
General Surgical population 1:1000 1:2000
Generally agreed upon rate for ED is 0.1%
 Failed Airway Definition
Three failed attempts at intubation
Failure to maintain SaO2 (typically above 90%)

Two types of failed airways

Cant intubate, CAN ventilate
Cant intubate, CANT ventilate
Second situation = surgical emergency = steel

Youve tried three separate attempts at

intubation and have not secured the airway

Alright, now you have a failed airway

Now what?
All Clear?

Excellent!

Any Questions?

Assess your situation:

First: can you sufficiently ventilate the patient with
BVM?
What is your back-up?
What rescue devices do you have available?
What is your confidence/experience with your
rescue devices?
Who is your back-up? How far away are they?
Is the patient a good candidate for EGDs? (RODS)
CAN YOU BAG THEM?
How much time do you have?

Your most comfortable and confident back up

device, whether it is a gum elastic bougie,
lightwand, or video laryngoscope should be on
hand for all intubations, checked and ready
 An EGD or LMA type airway should be used
in cases where endotracheal intubation was not
successful if the patient is a good candidate for
EGD. (RODS)

In the pre-hospital and emergency department

settings, the choice of EGD should be one that
can be used to intubate the patient and secure
the airway, as an EGD alone is not a secured
airway.

In any case of cant intubate, cant ventilate a

surgical airway must be performed and
secured.

Cricothyroidotomy or Tracheostomy kit or tray

should be ready and available.
My Cric Kit:
#10 blade scalpel
Cric hook
(actually I carry a $6 dissecting trochar)
 Direct Laryngoscopy
Benefits
Common, most experience
Standard equipment
No lens for contamination
Direct line of sight
Downfalls
Direct line of sight
Difficult with C-spine immobilization
Difficult with for anterior airways
Small, direct image of glottis

Supraglottic/Extraglottic Devices (EGD)

Benefits
Can often ventilate patients who were not able to be
intubated
Cheap
Easy to learn, easy to place
Can intubate through several of the models
(I argue that you should only stock intubating EGDs in emergency departments)

Downfalls
NOT A SECURED AIRWAY UNTIL INTUBATED
Limited ventilatory pressures
 Video Laryngoscopy
Becoming much more common
Research being done comparing DL vs. Video
laryngoscopy for success rates

Benefits
C-spine immobilization
Anterior view for anterior airway
Minimal mouth opening
Works well for patients who fail the 3-3-2 rule
Large, enhanced view of glottic opening

Video Laryngoscopy

Downfalls
Lens/camera contamination
Anterior position of airway requires sharp stylet
angle
Fogging

Awake fiberoptic
Benefits
Awake patients can maintain airway patency
NO mouth opening required
Maintain C-spine immobilization
Very small glottic opening required for successful
intubation
Downfalls
Lens contamination very poor in settings with trauma
or lots of secretions/blood/vomit
Very operator dependant for success rates
Very time consuming
Expensive equipment
 Surgical Airway
Benefits
Cheap, simple tools:
Blade
Tube
Cric hook (optional)
Cricothyroidectomy tray (optional)
Usually only option when required
Downfalls
Very invasive
Operator dependant for complications

Surgical Airway
Cric vs. Trach
Trach under 8
Cric the rest
 Needle Jet Ventilation
Oxygenation, NOT Ventilation
Works to buy you time only!
1 second inspiration, 2-3 seconds exhalation
What size ETT hub fits an angiocath?
3.0!

Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices
 Supraglottic Devices (non LMA style)
Typically in-field rescue devices
Not a secured airway
Smallest size is for 4 or taller patient
Combitube <$20
King LT <$20

Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Laryngeal Mask Airways

LMA $16
LMA Supreme ~$20
(port to decompress stomach)
Intubating LMA
ILA (Fastrach) $600
Air-Q $10-16
LMA C-Trach (Video LMA) $9000
 Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Semi-rigid and rigid laryngoscopes

Upsher
Bullard
ResQ Air
Truview

Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices
 Fiberoptic Stylets
Brambrink $3,400
FAST Foley Airway Stylet $2000
Can be used with Fastrach ILMA
Levitan $1400
Shikani Optical Stylet (SOS) $2500
Peds sized Shikani
Storz Bonfils $5,100

Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Flexible fiberoptic and videochip scopes

Storz
Olympus
Pentax
 Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Video Laryngoscopy
Airtraq 6/box $500/box
Glidescope $10,000
Glidescope Cobalt
Glidescope Ranger $10,000
Glidescope Ranger Cobalt
McGrath $10,000
Pentax Airway Scope AWS-S100 $10,000
Storz Video Laryngoscope $3,750/blade
Storz C-Mac $10,000
 Supraglottic Devices
Laryngeal Mask Airways
Semi-rigid and rigid laryngoscopes
Fiberoptic stylets
Flexible fiberoptic scopes
Video Laryngoscopy
Other airway backup devices

Other Airway backup devices

Gum Elastic Bougie $10
Grandview DL blade
Light wand / Lighted Stylet $80-$120
Cold hard steel $2
Cric hook $6-60
Cric hook $35-60
Dissecting trochar $6 (same hook, not as shiny)
 Take home messages:
Proper BVM, patient positioning, and ventilation
skills can save you from needing to intubate.

Have a backup, and be comfortable using it.

Breathe! If you dont, you patient wont, either.

Management of the Difficult and Failed Airway

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Rose DK, Cohen MM; The airway: problems and predictions in 18,500
patients
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