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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 163-167

Advanced airway management of paediatric patients with anticipated difficult airway


Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexandria, Alexandria, Egypt

Date of Submission07-Jan-2016
Date of Acceptance13-Feb-2016
Date of Web Publication16-Dec-2016

Correspondence Address:
Aliaa R. A. Abdel Fattah
Department of Anaesthesia, Alexandria University Hospital, Alexandria, 21648
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.195875

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  Abstract 

Background
Paediatric patients have significant anatomical and physiological differences compared with adults. Furthermore, there are a number of pathological processes, which present unique anatomical or functional difficulties in airway management.
Patients and methods
This randomized, controlled clinical trial included 60 children (≤5 years of age with abnormal height-to-thyromental distance ratio or COPUR scale ≥12) scheduled for surgery under general anaesthesia. The patients were randomly allocated into three groups: group I underwent fibreoptic laryngoscopy (3.7 mm) through AirQ-ILA; group II underwent Miller laryngoscopy with Bonfils optical stylet; and group III underwent C-MAC videolaryngoscopy. Number of intubation attempts, total time for endotracheal tube insertion, modified Cormack and Lehane score, time for successful intubation attempt, and need for assistance were recorded.
Results
The modified Cormack and Lehane grade 1 was achieved in all paediatric patients included in group I compared with 65% in group II and 40% in group III. As regards the number of intubation attempts, 90% of paediatric patients included in group I had successful first intubation attempt, compared with 45 and 30% group II and group III, respectively. As regards need for assistants, group I required higher number of assistants. The total time for endotracheal tube insertion was significantly shorter in group II (62±15 s) and group III (61±12 s), demonstrating that intubation was longer in group I (207±54 s), and the time for successful attempt was significantly shorter in group II (39±3 s) and group III (33±4 s) compared with group I (199±51 s).
Conclusion
Flexible intubating fibrescope was superior with regard to modified Cormack and Lehane score and number of intubation attempts, whereas intubation with Bonfils optical stylet or C-MAC videolaryngoscopy was superior with regard to need for airway specialized assistants or both time for endotracheal tube insertion and time for successful intubation attempt.

Keywords: anticipated difficult airway, Bonfils optical stylet, C-MAC videolaryngoscopy, flexible fibrescope, paediatric


How to cite this article:
Abdel Fattah AR, El Attar AM, Anwer HM, Ghoneim TA. Advanced airway management of paediatric patients with anticipated difficult airway. Res Opin Anesth Intensive Care 2016;3:163-7

How to cite this URL:
Abdel Fattah AR, El Attar AM, Anwer HM, Ghoneim TA. Advanced airway management of paediatric patients with anticipated difficult airway. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Feb 19];3:163-7. Available from: http://www.roaic.eg.net/text.asp?2016/3/4/163/195875


  Introduction Top


Airway management plays a pivotal role in paediatric anaesthesia. Paediatric airway poses a challenge because of their unique anatomy and physiology [1]. The anaesthesiologist must be able to protect the airway, adequately ventilate and adequately oxygenate. Failure to perform any one of these tasks will result in respiratory failure [2]. Over the last two decades many improvements in this area have helped us to overcome this final frontier [3].

In adults with anticipated difficult airway awake intubation is performed; however, in children with a difficult airway, intubation has to be performed under deep sedation or general anaesthesia [4]. During the process it is important to ensure that the patient is adequately oxygenated as well as anaesthetized. The aim of this work was to compare AirQ-ILA-assisted fibreoptic laryngoscopy, Bonfils optical stylet video-assisted laryngoscopy and C-MAC videolaryngoscopy in airway management of paediatric patients with anticipated difficult airway.


  Patients and methods Top


Approval of Alexandria University Hospital Ethics Committee was granted for this study, and all children’s parents provided informed written consent to participate. A total of 60 children scheduled for elective surgery under general endotracheal anaesthesia aged up to 5 years of both sexes with abnormal height-to-thyromental distance ratio or the COPUR scale [5] of 12 or greater to predict difficult airway were randomly allocated to three equal groups.

Preoperative airway assessment was carried out clinically using height-to-thyromental distance ratio and the COPUR scale. Laboratory investigations were carried out using coagulation profile and arterial blood gas analysis, and radiological examination of the upper airway was carried out using lateral low kilovolt plain radiograph of the neck taken on inspiration with the head in neutral position.

Preoperative preparation of all participating children was carried out using preoxygenation and blockade of airway reflexes achieved with nebulized lidocaine. It was used in conjunction with either inhalational or intravenous induction based on the signs of compromised of airway.

As regards intubation technique, the included children were randomly classified into three groups: group I underwent fibreoptic laryngoscopy (3.7 mm) through AirQ-ILA; group II underwent Miller laryngoscopy with Bonfils optical stylet; and group III underwent styletted endotracheal tube with C-MAC videolaryngoscopy.

Videos of all endoscopies were converted into video files and stored in a computer connected with Tele Pack. The following parameters were all measured by another anaesthesiologist who did not participate in the procedures: number of intubation attempts, modified Cormack and Lehane score, and time for successful intubation attempt.

Mean arterial blood pressure, pulse rate, arterial oxygen saturation, and end-tidal CO2 were measured just before and after successful intubation. Complications such as sore throat and hoarseness were checked by another anaesthesiologist who was blinded to this study immediately after surgery.

The time frame from the start of procedure (group I=AirQ LMA insertion, group II=Bonfils tip entrance, and group III=blade insertion) until the appearance of first wave of exhaled CO2 on capnography was considered as the total time of endotracheal tube insertion.


  Results Top


Patient characteristics were not significantly different between the three groups ([Table 1]). Mean arterial blood pressure was significantly higher in groups II and III compared with group I immediately and 2 and 5 min after intubation ([Figure 1]). Pulse rate was significantly higher in group II compared with group I, with a higher incidence of bradycardia in group III compared with group I and group II immediately after intubation, whereas 2 and 5 min after intubation pulse rate was significantly higher in groups II and III compared with group I ([Figure 2]).
Table 1: Comparison between the three studied groups as regards demographic data

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Figure 1: Changes in mean arterial blood pressure between the three groups.

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Figure 2: Changes in mean heart rate between the three groups.

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Oxygenation was not significantly different between the three groups both before and after intubation, but hypoventilation occurred immediately after intubation in group I compared with groups II and III ([Figure 3]).
Figure 3: Changes in mean end-tidal CO2 between the three groups.

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As regards comparison between the three intubation techniques, the results of the present study demonstrated that intubation with flexible intubating fibrescope through AirQ LMA was superior compared with the other two devices as regards modified Cormack and Lehane score ([Figure 4]) and number of intubation attempts ([Figure 5]).
Figure 4: Modified Cormack and Lehane score in the three groups.

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Figure 5: Number of intubation attempts in the three groups.

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However, intubation with Bonfils optical stylet or C-MAC videolaryngoscopy was superior compared with intubation with flexible fibrescope with regard to need for airway specialized assistants ([Figure 6]) or both time for endotracheal tube insertion ([Figure 7]) and time for successful intubation attempt ([Figure 8]).
Figure 6: Need for assistance in the three groups.

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Figure 7: Mean tube insertion time in the three groups.

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Figure 8: Mean time of successful intubation attempt in the three groups.

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The total time for endotracheal tube insertion was significantly shorter in group II (mean time: 62±15 s) and group III (mean time: 61±12 s), demonstrating that intubation was longer in group I (mean time: 207±54 s).

The time for successful attempt was significantly shorter in group II (mean time: 39±3 s) and group III (mean time: 33±4 s) compared with group I (mean time: 199±51 s).

There was no statistically significant difference between the three groups as regards incidence of complications ([Figure 9]).
Figure 9: Incidence of complications in the three groups.

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  Discussion Top


Paediatric airway may be complicated by a number of syndromes involving the head, neck, and cervical spine. These syndromes may result in difficulty in establishing or maintaining gas exchange through a mask, an artificial airway, or both [6]. Many methods and instruments have been developed to assist difficult intubation. In this study, we compared the effectiveness of three tools, the flexible intubating fibrescope, Bonfils optical stylet, and C-MAC videolaryngoscopy.

The present study showed that the flexible intubating fibrescope with a mobile distal tip had lesser intubation pressor response compared with immobile tip of Bonfils optical stylet or blade of C-MAC videolaryngoscopy, thus having a higher probability of stimulating laryngeal surface. In agreement with the current study, Boedeker et al. [7] documented that flexible intubating fibrescope had fewer hemodynamic changes compared with Bonfils optical stylet.

The current study documented that 20% of paediatric patients intubated with C-MAC videolaryngoscopy developed bradycardia as a result of vagal stimulation due to laryngeal stimulation, which had been recorded immediately after intubation. In agreement with the present study, Jones et al. [8] studied causes of bradycardia during critical care intubation and concluded that bradycardia occurs during the intubation of some children as a result of vagal stimulation due to hypoxia and/or laryngeal stimulation.

A long intubation time was a leading cause of hypoventilation documented in the current study immediately after flexible fibrescope intubation. In agreement with our study, Bein et al. [9] documented that the hypoventilation occurred during intubation with flexible fibrescope due to longer intubation time.

In the current study, the modified Cormack and Lehane grade 1 was successfully achieved in all paediatric patients included in group I, which was statistically significantly higher compared with 65% achieved in group II and 40% achieved in group III. In agreement with the present study, Kim et al. [10] documented that participants using the Bonfils fibrescope recorded an average Cormack and Lehane airway score of 2; with the flexible fibrescope, the recorded average airway grade improved to 1.

As regards number of intubation attempts, 90% of paediatric patients included in group I had successful first intubation attempt, compared with 45 and 30% of patients in group II and group III, respectively. In agreement with our results, Jagannathan et al. [11] evaluated the use of the AirQ as conduit for fibreoptic intubation in 100 children aged 6 months to 8 years. They reported a first attempt success rate of 97%.

As regards need for assistant, group I required significantly higher number of assistants to lend a hand either in guidewire or railroading technique compared with group II and group III.

The total time for endotracheal tube insertion and time for successful intubation attempt were significantly shorter in group II and group III compared with group I. In agreement with our study Rudolph et al. [12] reported that intubation using Bonfils endoscope was shorter than that using the flexible fibreoptic intubation, whereas Ofelia et al. [13] showed that the intubation time was consistently shorter in the C-MAC group compared with fibreoptic group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Benumof JL. The ASA difficult airway algorithm: new thoughts considerations. Annual refresher course lectures. Am Soc Anesthesiol. 1997; 241:1–7.  Back to cited text no. 1
    
2.
Ovassapian A, Meyer RM. Airway management. In: Longnecker DE, Tinker JH, editors. Principles and practice of anesthesiology. 2nd ed. Philadelphia: Mosby; 1998. 49.1076–1078.  Back to cited text no. 2
    
3.
Roberts JT, Pino R. Functional anatomy of the upper airway. In: Roberts JT, editor. Clinical management of the airway. Philadelphia: WB Saunders 1994. 2–39  Back to cited text no. 3
    
4.
Didem D. Airway management in a high risk infant with multiple congenital anomalies and difficult airway. Acta Anaesthesiol Scand 2004; 48:927.  Back to cited text no. 4
    
5.
Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891–897.  Back to cited text no. 5
    
6.
American Society of Anesthesiologists Task Force on Difficult Airway Management. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269–1277.  Back to cited text no. 6
    
7.
Boedeker BH, Barak-Bernhagen MA, Miller DJ, Nicholas TAIV, Linnaus A, Murray WB. Improving rigid fiberoptic intubation: a comparison of the Bonfils intubating fiberscope with a novel modification. BMC Emerg Med. 2010; 10:11.  Back to cited text no. 7
    
8.
Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance and atropine. Arch Dis Child 2012; 97:139–144.  Back to cited text no. 8
    
9.
Bein B, Worthmann F, Scholz J, Brinkmann F, Tonner PH, Steinfath M et al. A comparison of the intubating LMA and the Bonfils intubation endoscope in patients with predicted difficult airways. Anaesthesia 2004; 59:668–674.  Back to cited text no. 9
    
10.
Kim SH, Woo SJ, Kim JH. A comparison of Bonfils intubation fiberscopy and fiberoptic bronchoscopy in difficult airways assisted with direct laryngoscopy. Korean J Anesthesiol. 2010; 58:249–255.  Back to cited text no. 10
    
11.
Jagannathan N, Kozlowski RJ, Sohn LE, Langen KE, Roth AG, Mukherji II et al. A clinical evaluation of the intubating laryngeal airway as a conduit for tracheal intubation in children. Anesth Analg 2011; 112:176–182.  Back to cited text no. 11
    
12.
Rudolph C, Henn-Beilharz A, Gottschall R, Wallenborn J, Schaffranietz L. The unanticipated difficult intubation: rigid or flexible endoscope? Minerva Anestesiol. 2007; 73:567–574.  Back to cited text no. 12
    
13.
Ofelia L, Lazo E, Yumul R, Lennon C. A randomized prospective study comparing tracheal intubation with C-MAC device to fiberoptic bronchoscopy in patients undergoing cervical spine surgery. Am Soc Anesthesiol 2011; 274–279.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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