The Science Journal of the American Association for Respiratory Care
Background: Differences in anatomy between the adult and child larynx challenge the practitioner to utilize variable techniques in order to successfully intubate the pediatric patient. Because no pediatric airway algorithm exists, we evaluated the adult American Society of Anesthesiologists (ASA) Difficult Airway Algorithm1 for use with children. Use of Laryngeal Mask Airways (LMA) and flexible fiberoptic bronchoscope are recommendations within the Difficult Airway Algorithm. These findings, along with the availability of smaller sizes of these instruments, inspired us to incorporate them into our practice, for use by Critical Care Medicine/Anesthesia physicians in the Pediatric Intensive Care Unit (PICU). An airway assessment tool was developed in order to identify those pediatric patients who were considered to have a difficult airway and may therefore require the use of these instruments. Respiratory Care Practitioners (RCP's) were educated to assist Critical Care Medicine/Anesthesia with the implementation of the LMA.
Method: Data was collected on all patients requiring intubation in the PICU and Operating Room. Patient history, diagnosis, prior intubations, airway assessment, including the Mallampati Score (>3 years of age)2, the anterior mandibular space-thyromental distance, dental exam, oropharnygeal-nasopharnygeal exam, and c-spine immobilization were included in the data collection. In addition, data was collected regarding ventilation technique prior to intubation, level of training of personnel, complications of airway management, and intubation procedure including: patient's level of consciousness, instrumentation used, number of attempts, cricoid pressure and size and type of airway placed.
|Successful Intubations||Class I & II (easy) Mallampati Score||Class III & IV (difficult) Mallampati Score|
|1 Attempt||91 (86%) *||4 (4%) *|
|Multiple Attempts||6 (6%)||4 (4%) *|
|n = 105|
* The airway assessment tool was successfully used in classifying and evaluating 94% of the patients.
Conclusions and Recommendations: The pilot use of this pediatric airway assessment tool enhanced our ability to identify patients at risk for difficult airway management. It identified a potential need for the use of LMA's and flexible bronchoscope to facilitate successful intubation. Continuing data collection and further evaluation is needed to validate the use of a pediatric-based algorithm and develop a composite scoring system for early identification of high-risk patients.
1. American Society of Anesthesiologists Task Force. Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993; 78(3): 597-602.
2. Stoelting, RK, Miller RD: Basics of Anesthesia 3rd ed. New York, Churchill Livingstone, 1994, pp145-162.