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Difficult Pediatric Airway
Case Synopsis
A 3-year-old child is scheduled for tonsillectomy and adenoidectomy. His past medical history is significant for Treacher Collins syndrome ( Fig. 188.1 ), and thus a difficult airway is anticipated. After inhalation induction with spontaneous respirations, successful intubation is performed with the use of a fiberoptic bronchoscope via a supraglottic device placement.
Acknowledgment
The author wishes to thank Dr. Hernando De Soto for his contribution to the previous edition of this chapter.
Problem Analysis
Definition
A difficult airway is one in which there is moderate-to-severe difficulty in performing mask ventilation, direct laryngoscopy, or both. This situation may result from anatomic (congenital or acquired) or physiologic defects.
Recognition
Performing a thorough history and physical examination is the best means of recognizing and predicting a difficult pediatric airway. Understanding the significant differences between the pediatric and adult airways is mandatory for the successful management of a child with a difficult airway ( Fig. 188.2 ). Anatomic differences exist in the size, shape, and position of the airway, as well as the airway epithelium and its supporting structures. Physiologic differences between the neonatal and adult respiratory systems are due to differences in anatomy and respiratory control mechanisms.
Upper Airway
The upper airway of the newborn is unique. The tongue is relatively large and fully occupies the cavity of the mouth and oropharynx. This may make manipulation of the laryngoscope and endotracheal tube more difficult during attempted intubation. Neonates are obligate nose breathers up to about 6 months of age. This is because the epiglottis, positioned high in the pharynx, almost meets the soft palate, making mouth breathing difficult.
Lymphoid Tissue
Unlike older infants and children, neonates have almost no upper airway lymphoid tissue. The tonsils and adenoids appear during the second year of life and reach their maximum size by 4 to 7 years of age, and after that they gradually recede. Enlarged tonsils and adenoids may increase bleeding during attempted nasal intubation.
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