Anesthetic Implications In Neonates & Children: Airway management Speaker: Dr Vandna Arora Moderators: Dr Sujata Chaudhary Dr Chhavi Sharma University College of Medical Sciences & GTB Hospital, Delhi

Complicating anatomical factors in infants Narrow nares, chubby cheeks Rendell Baker mask Large tongue Straight blade laryngoscope Large occiput Head in neutral position during intubation Narrow cricoid ring Appropriate sized ETT High glottis

Funnel shaped larynx of an infant(b) compared to cylindrical shape of the adult larynx(a)

Miller’s blade

Rendell-Baker mask

Oral Airways

Size of ETT Cuffed ETT: [age(years)/4]+3 AgeInternal diameter of ETT Recommended size of laryngoscope straight blade Distance of insertion(cm) Preterm (<1250g) 2.5 uncuffed06-7 Full term3.0 uncuffed yr cuffed111 2 yr cuffed yr cuffed yr cuffed yr7-8 cuffed319

Uncuffed Endotracheal Tubes

Microcuff Endotracheal Tube

Laryngeal Mask Airway Weight(kg)Size of LMAGas volume (ml) < >50430

Evaluation of the pediatric airway History Presence of URI Snoring or noisy breathing Presence & nature of cough Past episode of croup (post intubation) Inspiratory stridor Hoarse voice Asthma & bronchodilator therapy Repeated pneumonias h/o foreign body aspiration h/o aspiration Previous anesthetic problems, particularly related to airway Atopy or allergy h/o smoking by primary care givers h/o congenital syndrome

Examination Facial expression Presence or absence of nasal flaring Presence or absence of mouth breathing Color of mucus membrane Presence or absence of retractions Respiratory rate Presence or absence of voice change Mouth opening Size of mouth Size of tongue & its relationship to other pharyngeal structures Loose or missing teeth Size & configuration of palate Size & configuration of mandible Location of larynx in relation to the mandible Presence of stridor Baseline oxygen saturation in room air

Assessment of difficult airway in pediatric patient C- CHIN O- Opening of the mouth P- previous intubation or OSA U- UvulaR- Range From side view patient’s chin : Interdental space ( mouth open, tongue out) Estimate range of motion looking up & down Normal : 1> 40 mm : 1Previous attempt easy : 1 Whole of uvula visible : 1 > 120 ˚ : 1 Small, moderately hypoplastic : mm : 2No previous attempt, no h/o OSA : 2 Uvula partially visible : ˚ : 2 Markedly recessive : mm : 3OSA, previous h/o difficult intubation : 3 Uvula concealed, soft palate visible : ˚ : 3 Extremely hypoplastic : 4 < 10 mm : 4Extremely difficult previous intubation, tracheostomy : 4 Soft palate not visible : 4 < 30 ˚ : 4

Prediction points 5-7 : easy, normal intubation 8-10 : laryngeal pressure may help 12 : increased difficulty, fibreoptic may be preferred 14 : difficult intubation, fibreoptic or other advanced technique should be preferred 16 : dangerous airway, consider awake intubation, potential tracheostomy ( Lane G. Intubation Techniques. Operative Techniques in Otolaryngology 2005;16: )

Diagnostic testing Plain radiographs of upper airway Fluoroscopy CT MRI Flexible fibreoptic endoscopy Blood gas analysis Radiological evaluation should not take precedence over airway control in patients with a compromised airway

Summary Psychological preparation of children preoperatively is associated with better outcomes Premedication is required to decrease separation anxiety Standards for basic anesthesia monitoring should be followed in all anesthetics Neonatal kidney is immature at birth & unable to excrete large water load Isotonic fluids are preferred intraoperatively Anatomical differences should be kept in mind while managing airway in neonates & children

References Miller’s text book of anesthesia, 7 th edition A practice of anesthesia, Wylie, 7 th edition. Textbook of pediatric anesthesia, 3 rd edition, Hatch and Sumner’s Pediatric anesthesia, 4 th edition, Gregory Smith’s Anesthesia for infants & children, 7 th edition Hagberg CA. Benumof's Airway Management, 2 nd edition Cote CJ, Lerman J, Tordes ID. A practice of anesthesia in infants and children, 4 th edition Lane G. Intubation Techniques. Operative Techniques in Otolaryngology 2005;16: APA consensus guideline on perioperative fluid management in children v 1.1 September 2007 © APAGBI Review Date August 2010

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