Infant Videolaryngoscope

The various forms of this device on the market allow for excellent glottic visualization and facilitation of intubation if the mouth opening is large enough to accommodate the blade and can provide superior visualization compared to conventional direct laryngoscopy in some patients.

Intubation Through a Laryngeal Mask Airway

Securing the airway with an LMA and demonstrating that one can ventilate through it can add an extra margin of safety when performing an anticipated difficult pediatric intubation. The LMA is then used as a conduit for the insertion of the fiberoptic-guided endotracheal tube into the glottis.

Retrograde Cricothyroid Wire

This technique is not ideal for this patient for many reasons. First, the size of the patient would make it technically difficult. Second, the large cystic hygroma distorts the external anatomy landmarks that facilitate this type of intubation. Given newer developments in pediatric airway management, this approach is rarely used.

Blind Nasal Intubation

Although very successful in adult patients, the blind nasal intubation technique can be very challenging in infants or small children. Performing an awake sedated intubation in this manner mandates giving adequate topical anesthesia to a less-than-cooperative infant. In addition, the smaller endotracheal tubes used in pediatrics are far more compliant than adult-sized tubes, especially when warmed with nasopharyngeal respiratory gases, which makes it difficult to maintain the anterior curve on the tube to enter the larynx.

Nasal Intubation With Laryngoscope and Magill Forceps

If the larynx cannot be visualized by direct laryngoscopy, an anesthetized, spontaneously breathing nasal intubation with laryngoscopic assistance can be carried out in some patients. In this case, great care is taken to ensure that the patient continues to maintain spontaneous and adequate ventilatory exchange during the inhalational induction. Sevoflurane is used for pediatric inhalational inductions because it is less pungent and more easily tolerated than other agents. The pediatric anesthesiologist should be mindful that total airway obstruction can happen at any point during the inhalation induction due to the relaxation of pharyngeal tone and other airway abnormalities. If spontaneous breathing can be maintained, intubation should be attempted after a surgical plane of anesthesia is achieved. The laryngoscope is then used to visualize the epiglottis. Using Magill forceps, the tip of the endotracheal tube is aligned with the subepiglottic region and slowly advanced. Capnographic monitoring during this maneuver can help verify the direction of the endotracheal tube tip.

Fiberoptic Intubation

Fiberoptic intubation is most successful when it is carried out as the initial maneuver before the airway is traumatized from previous attempts at intubation. It can be nearly impossible to use after several unsuccessful attempts because the upper airway becomes hypersecretory and bloody. The appropriate fiberoptic technology is not widely available unless one is practicing at a tertiary pediatric hospital with a wide range of airway devices (including the smallest, "ultrathin" 2.2 mm in diameter fiberoptic scope necessary for this neonate). Due to their small size, pediatric bronchoscopes lack a suction port and need to be lubricated to facilitate the sliding of the endotracheal tube off the scope once it is through the glottis.

In older patients, three specialized fiberoptic methods can be useful in intubating pediatric patients with difficult airways. First, the clinician can pass a guidewire through the suction port of the larger instrument to serve as a stylet for the endotracheal tube. Second, the scope can be used to visualize and guide a nasal endotracheal tube inserted into the opposite nostril. Finally, a 4.5-mm tube can be placed at the laryngeal orifice to be used as a stent for inserting a small guidewire, which can in turn be used to place a smaller endotracheal tube.

Combined Videolaryngoscopy and Fiberoptic Intubation

A common pitfall with the use of videolaryngoscopes is identifying a view of the larynx but being unable to pass the tracheal tube, especially in a patient with an anterior airway. To avoid this pitfall, a combined technique of videolaryngoscopy and fiberoptic intubation can be utilized. First, a videolaryngoscope is inserted into the oropharynx to obtain a view of the vocal cords. A tracheal tube is placed over a flexible fiberoptic scope, inserted into the oropharynx, and dually guided through the vocal cords with visualization from both the videolaryngoscope and fiberoptic scope. This technique allows for an increased range of motion with the fiberoptic scope as well as displacement of the tongue and soft tissue with the videolaryngoscope to angle the tracheal tube through the laryngeal inlet.

Transtracheal Jet Ventilation

For this technique, a 16-gauge intravenous catheter is placed through the cricothyroid membrane, and jet ventilation with 100% oxygen is provided. A second intravenous catheter is placed through the cricothyroid membrane, and a guidewire (0.021-in. diameter J-tip) is introduced with cephalad angulation. Jet ventilation continues, as the guidewire is threaded through the nose and connected to the working part of a fiberoptic scope. The scope is then advanced through the laryngeal inlet, and a tube is threaded over the scope and then the guidewire is removed. Sedation can be provided with a remifentanil infusion (0.1-0.2 µg/kg/min) or dexmedetomidine infusion (0.5-1 µg/kg/h). Because patient safety is the foremost consideration in any technique for inserting an artificial airway, an anesthesiologist or otolaryngologist should be immediately available to perform an emergent cricothyrotomy in case of life-threatening loss of airway.

In a pediatric patient with a known difficult airway, a preemptive collaborative approach of securing the airway with a pediatric otolaryngologist can greatly increase the degree of safety and minimize harm. Pediatric surgeons can also be consulted in case ECMO is required during acute decompensation during difficult airway management. Passive oxygenation and supplemental oxygen should be utilized during every attempt with the airway to prolong the time to desaturation. When performing an emergency cricothyrotomy, a longitudinal incision is made in the skin and fascia above the cricothyroid membrane, after which the cricothyroid membrane is punctured and entered with a small endotracheal tube. Another technique utilizes an 18-gauge angiocatheter (or larger), which is inserted into the cricothyroid membrane. Intratracheal location is verified by the loss of resistance with an attached syringe and the aspiration of air. The catheter is attached to a 3-mL syringe (without plunger), which is then connected to the Y-piece of the anesthesia circuit by an adapter from a 3.0-mm internal diameter endotracheal tube.

References

• Dhanyee AS, Pillai R, Sahajanandan R. Wire guided fibreoptic retrograde intubation in a case of glottic mass. Indian J Anaesth. 2016;60:219-221.
• Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N. Error traps in pediatric difficult airway management. Paediatr Anaesth. 2021;31:1271-1275.
• Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth. 2020;30:269-279.
• Tsao M, Vargas AA, Hajduk J, et al. Pediatric airway management devices: an update on recent advances and future directions. Expert Rev Med Devices. 2018;15:911-927.