Indian J.
PG
300 ISSUE2005;
Anaesth. : AIRWAY
49 (4) : MANAGEMENT
300 - 307
AIRWAY MANAGEMENT IN CHILDREN
Dr. Pankaj Kundra1
Introduction
Paediatric airway management remains the most
daunting task before the anaesthesiologist. However, the
laryngeal structures are so soft and pliable that external
laryngeal manipulation of the airway makes the task much
easier than expected. Often in the absence of a fibreoptic
scope unconventional or alternative methods are used to
secure the airway with success. Success of any such
technique depends upon constant maintenance of an
unobstructed airway and sufficient satisfactory depth of
anaesthesia during the airway manipulation.1
Difference between adult and paediatric airway
Understanding the anatomical and physiological
features of paediatric airway facilitates the development of
a rational set of strategies to manage normal and difficult
paediatric airway patients. When the differences are
understood it will be clear that paediatric airway is a
different airway and not a difficult airway.
Infants have small nares and nasal passages. In infants
head is large compared to body size resulting in automatic
sniffing position without elevation of occiput. Infants have
a large tongue in relation to oral cavity. Base of tongue is
situated in close proximity to laryngeal inlet. This caudal
insertion is called glossoptosis. Tonsils are small in newborn
but it grows to maximal size at 4 – 7 years of age. Enlarged
tonsils may obscure laryngeal view or may interfere with
mask ventilation. In infants epiglottis lies at the level of C1
(adults C3) touching the soft palate separating oesophageal
inlet from laryngeal inlet2 hence infants are obligate nose
breathers till 2 – 6 months of age, the ability to breath
orally is age related and increases with postnatal age.3 The
epiglottis in infants is large stiff and omega shaped compared
to short broad and flat epiglottis of adults (fig. 1). Epiglottis
sits at 45o angles to anterior pharyngeal wall (adults 20o),
as a result of which epiglottis should be picked up with the
blade for better visualization of glottis. Larynx lies in a
1. M.D.,MAMS, FIMSA, Prof.
2. M.B.B.S., Junior Resident
Dept. of Anaesthesiology and Critical Care
Jawaharlal Institute of Postgraduate Medical Education
and Research, Pondicherry 605006
Correspond to :
Dr. Pankaj Kundra
D – II/21, JIPMER Campus. Pondicherry 605006, India
E- mail : pankajkundra@vsnl.net, p_kundra@hotmail.com
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
300
Dr. Hari Krishnan S.2
more cephalic position C3 – C4 at birth, C4 – C5 at 2 years
of age, C5 – C6 by adulthood (fig. 1). A cephalic and
superior position on larynx in infants creates more acute
angulations between glottis and base of tongue hence
posterior displacement is often necessary to improve the
view. Larynx is funnel shaped (cylindrical in adults) till
6–8 years of age because cricoids cartilage (glottis in adults)
is the narrowest part of airway. The vocal cords are bow
shaped making an angle with anterior commissure, where
as the plane of vocal cords is perpendicular to long axis of
trachea and vocal cords are linear in adults (fig. 1). This
angulations of vocal cords increase the chance of endotracheal
tube (ETT) abutting the anterior commissure during blind
intubation.
Fig. 1 : Schematic diagram showing the difference between adult and
paediatric airway.
Trachea in infants is short narrow and angled
posteriorly resulting in accidental endobronchial intubation
or extubation with changes in head position. Ribs are
horizontal with decreased anterior posterior and cephalic
movements; hence the diaphragm is the mainstay of
ventilation in neonates. The angle formed by abdominal
wall and diaphragm is more acute in infants, which reduces
the mechanical efficiency during contraction. In addition
infants have higher percentage of type II fibres4 (fast
twitch low oxidative) in their respiratory musculature leading
to early appearance of respiratory fatigue.
Congenital airway anomalies and airway management
in these children
Paediatric airway may be complicated by a number
of syndromes involving head neck and cervical spine. These
syndromes may result in difficulty in establishing or
maintaining gas exchange via a mask, an artificial airway
or both (table 1).
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 301

Table - 1 : Congenital syndromes associated with Table - 2 : Agents used for sedation
difficult airway.
Drugs Advantages Disadvantages
Anatomical Location Syndrome Anomaly Midazolam Amnesia, reversible Airway reflexes not blunted
Head Hydrocephalus Macrocephaly Opioids Reversible Risk of apnoea
Mandible Pierre Robin Sequence Micrognathia & Ketamine Adequate spontaneous Post anaesthetic delerium,
and Treacher Collin’s Mandibular Hypoplasia ventilation. Prevents Sympathetic stimulation.
Syndrome airway reflexes during Increased airway secretions.
airway manipulation No reversal agent
Mid Facial Apert’s Syndrome Maxillary Hypoplasia

Temporomandibular Joint Arhrogryposis Ankylosis The advantages of awake intubation are preserving
Cocayane Syndrome
of normal airway tone and respiratory efforts. The
Mouth and Tongue Down’s Syndrome Macroglossia
disadvantages are a struggling child, increased haemodynamic
Mucopolysaccharadosis Macroglossia responses and the risk of raise in intracranial pressure.7
Freeman Sheldon We suggest a plan for airway management in anticipated
Syndrome Microstomia difficult airway.
Neurofibromatosis Masses obstructing
airway Inhalational Induction
In child with difficult but “uncompromised airway”
Struge Weber Masses obstructing
Syndrome airway inhalation induction is by far the preferred choice. The
success of inhalation induction will depend upon the
Dental Cocayane Syndrome Protruding Incisors
maintenance of airway patency throughout induction and
Cervical Spine Klippel- Fiel Syndrome Limited Mobility
ensuring adequate depth of anaesthesia before airway
Down’s Syndrome Instability manipulation. Halothane is the agent of choice. Sevoflurane
can also be used but because of its low solubility the depth
Airway assessment of anaesthesia rapidly diminishes during laryngoscopy.8
Prediction of difficult airway by the Samsoon and However, rapid recovery is one of the features that can be
Young modification of Mallampati classification in 476 of immense advantage in a child who develops airway
children between 0 (new born) to 16 years of age suggested obstruction following induction. The choice of an inhalational
an inaccurate prediction of a poor view during direct agent becomes irrelevant if a smaller size endotracheal
laryngoscopy. The assessment is often hampered by lack of tube is used as a nasopharyngeal airway in maintaining a
co-operation in infants and young children.5 No control patent upper airway and serve as a conduit to deliver
trials are yet available for evaluation of mandibular space, uninterrupted anaesthetic agent.1,9 In the meanwhile, the
neck mobility and jaw movements to predict difficult mouth or the other nostril can be used for securing the
laryngoscopy in paediatric population. Thus measurement airway.1 This facilitates control of the anaesthetic depth
of mentohyoid, thyromental, mandibular and inter dental necessary for airway manipulation. The same endotracheal
lengths have no value to predict difficult airway in tube can be advanced into the glottis. The depth of
paediatric patients. anaesthesia can be maintained if inspired agent
concentration is sufficient to offset the dilutional effects of
History of snoring,6 apnoea, daytime somnolence and room air. The advantage of this technique is that spontaneous
stridor may be indicative of airway obstruction, which may ventilation is preserved during airway instrumentation.
be exaggerated after induction. Physical examination should
include evaluation of the size and shape of head, gross Intravenous induction
facial features, size and symmetry of mandible, size of Targeting an adequate plane of anaesthesia without
tongue, prominence of upper incisors and range of motion compromising spontaneous ventilation is difficult with
in jaw, head and neck. intravenous induction agents. Propofol provides rapid
awakening and blunts airway reactivity. It is a good drug
Anaesthetic techniques
that permits a quick assessment of the laryngoscopic airway
In patients with difficult airway an awake intubation
grade. In addition a better control of the airway can be
is often the primary approach of airway management under
achieved with laryngeal mask airway (LMA) insertion under
sedation and adequate application of local anaesthetics to
propofol. The main disadvantage is the risk of apnoea,
the airway. Various agents have been used for sedation. It
which warrants extremely careful titration of an effective
is important to preserve spontaneous ventilation during
dose.
sedation (table 2).
302 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

Table - 3
Patient weight 4% Lignocaine (ml) Normal saline (ml)

10 – 14.9 0.5 0.5

15 – 19.9 1.0 1.0

20 – 24.9 1.5 0.5

25 – 29.9 2.0

30 – 34.9 2.5

35 – 39.9 3.0
Fig. 2 : Different blades used for laryngoscopy in children
A - Magill’s blade B - Macintosh blade
C - Bizzari-guffirda blade D - Wisconsin blade Rigid laryngoscopy
The keys for success with conventional rigid
Topical anaesthesia laryngoscopy includes age appropriate positioning, proper
Topical anaesthesia of airway improves child’s equipment selection, meticulous technique, minimal
acceptance of an airway device and blocks airway reflexes. number of attempts and optimal external laryngeal
It can be used in conjunction with either inhalational or manipulation (OELM)
intravenous induction once sufficient anaesthetic depth is Ideal position for infants and children under 2 years
reached for the child to tolerate laryngeal stimulus. of age is slight head extension without elevation of head
Lignocaine 10% spray is highly effective and care should with a roll under shoulders.10 A roll under the shoulders
be taken not to exceed the toxic dose limit. Except for helps to keep both the head and the shoulders lie in the
translaryngeal block all techniques used in adults can be same horizontal line. OELM is particularly useful for
used in children. Nebulized lignocaine is particularly useful children with limited mobility of cervical vertebrae and in
and can be used preoperatively or during induction with an infants.
inline attachment for nebulization to the anaesthetic circuit
(table 3).

Optimize child with premedication

Inhalational Induction

Assess airway patency on spontaneous ventilation

(Airway obstruction despite oropharyngeal airway?)

No airway obstruction Airway obstructi Fig. 3 : Laryngoscope blades

Maintain anaesthesia Use LMA

Intubation
Obstruction Obstruction Choosing laryngoscopes
persists relieved
Success Failure In general straight blade laryngoscopes are easier to
Awaken Type of surgery
use in infants and small children because of better alignment
of airway axis and reduced need for displacement of soft
Intubation Choices Aspiration Aspiration
likely unlikely tissue structures. Depending on the clinical situation certain
Non Surgical Surgical LMA as conduit Continue LMA
modified blades may be more effective for glottis
visualization (table 4).
1. Direct Laryngoscopy 1. PNC & TTJV* 1. Blind intubation
η Special Blades 2. PDC** 2. Fibreoptic assisted
η Retromolar approach 3. Tracheostomy 3. Guide wire assisted Retromolar approach
2. Flexible Fibreoptic Scope 4. Fibrescope and Guide wire
o
3. 70 Rigid Nasendoscope If difficulty is due to small mandible or a large
3. Blind Techniques
tongue this approach helps. The blade is introduced from
η Tactile the extreme right corner between the tongue and lateral
η Light wand
η Retrograde pharyngeal wall. The blade is advanced while staying to the
4. Combined Technique
η Retrograde wire and fibreoptic
right overlying the molars, until epiglottis or glottis is
* PNC & TTJV = Percutaneous needle cricothyrotomy and transtracheal jet ventilation seen. The proximal end of the blade is then brought to the
** PDC = Percutaneous dilational cricothyrotomy
midline. If glottis is not visualized the head can be turned
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN 303

to the left to improve visualization. The higher rate of LMA is available in five sizes for use in paediatric
success is due to bypassing of tongue, incisors and maxillary patients. An LMA that is too large will be difficult do
structures.11 place. An LMA that is too small will not form a tight seal
and may be difficult to use if positive pressure ventilation
Table - 4 is required. Numerous methods are described for placing
the LMA in infants and children. The overall success rate
Clinical situation Modifications Examples of insertion during first attempt ranges from 67–90%.
Limited mouth Reduced step height and area Miller blade Dubreil et al17 showed the first attempt success rate of
opening of flange (fig. 3) LMA size 1 is 67% and size 2 to be 78%, however when
mean attempts and complication rate are compared there
Reduced mandibular Wide blade effectively Bizzari-Guffirda
space compresses tongue in blade (fig. 2C) was no significant difference. O’neil et al18 found partially
mandibular space inflating the cuff resulted in higher success rate and a
Macroglossia Sides of tongue hindering vision, Wisconsin blade
shorter time of insertion. LMA can be placed while it is
blades with adequate cross (fig. 2D, 3) rotated 90o in the lateral oropharynx to bypass base of the
sectional area with a slight Magill’s blade tongue and then rotated to 90o back to its correct placement.
opening in vertical plane/tubular (fig. 2A)
in cross section helps
Guedel’s method involved turning back the LMA with mask
opening facing the palate once the base of tongue it bypassed
Anterior larynx Blade with more pronounced Fink’s blade it is rotated to 180o. Kundra et al,19 described a partially
terminal curve enables the Philip’s blade
hyoid cartilage to be reached
deflated lateral insertion technique with a better 1st attempt
via the vallecula effectively success rate than the classical technique described by Brain.
pushing it forward The technique describes a partially inflated cuff by the
lateral approach that is relatively free of mechanical
Blind nasal intubation hindrance and allows a free passage as used for insertion
A well lubricated softened endotracheal tube (ETT) of the laryngoscope blade.
is introduced into a naris. The left naris is preferred as
The flexible reinforced LMA (RLMA) resists thinking
the leading edge stays in midline in hypopharynx, if right
and can be positioned to minimize interference with surgical
naris is used the leading edge frequently hitches the right
procedures involving lead in neck. It is available in sizes
vallecula. The ETT is directed into glottis by hearing for
2–5. It is slightly difficult to insert compared to classical
breath sound, or by capnograph trace. Successful placement
LMA. It is particularly useful in children with difficult
often will need manipulation of ETT, patients head and the
airway undergoing Head and neck surgeries.
larynx. A stylet with 30o angle can be placed into ETT
after it is placed in nasopharynx.12 Posterior manipulation LMA proseal specially designed for children (size
of stylet will displace the distal end of ETT anteriorly and 1.5–2.5) is now available. One of its main features is the
into the glottis. Elective blind nasotracheal intubation in lack of rear cuff. In children there is no difference in ease
prone position for a neonate with Pierre-Robin sequence of insertion and seal pressure between proseal and classical
has also been described.13 Higher failure rates are found in LMA.20 In contrast to adult studies, greater sealing pressure
patients with mid facial hypoplasia. and lower success rate of insertion in proseal LMA was not
observed in children. Proseal LMA offers no great advantage
Laryngeal mask airway against aspiration in children but the provision of drain tube
LMA has revolutionized difficult airway management may help to empty air insufflated stomach in paediatric
in children. LMA has been successfully used in paediatric patients with difficult mask ventilation.
patients in whom ventilation or intubation are extremely
LMA has been used a conduit for in intubation.21-23
difficult or impossible. LMA has been used.
Intubation through LMA can be blind, fibreoptic assisted,
• In recognized difficult airway for awake tracheal light wand assisted or retrograde assisted. Blind techniques
intubation.14 has variable success rate. Rowbothom et al24 evaluated the
• In difficult intubation when mask ventilation is adequate, position of LMA (size 1 – 3) in 100 patients. 98% of cases
LMA is used as a definitive airway or as a conduit had a patent airway but LMA was in perfect position in
for intubation.15 49% of patients, further in 15% of patients impingement of
epiglottis into aperture bars was noted hence the safest
• When both mask ventilation and intubation becomes approach to place ETT through LMA is through fibreoptic
difficult, LMA can be used as ventilation device.16 scope. Kundra et al19 demonstrated that there occurs a
304 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

direct correlation with the fibreoptic view grading of the

glottis through the LMA and subtle airway obstruction. A
higher grade was associated with a gradual rise in end tidal
carbon dioxide in spontaneously breathing children though
the oxygen saturation remains within normal limits in short
surgical procedures lasting around half an hour. Blind
insertion of ETT through an improperly positioned LMA Fig. 4 : Differences in the field of
will lead to airway trauma. vision between a zero degree endoscope
and a 70-degree endoscope
LMA classic
Mask size Patients size Maximum cuff Largest is made with 20/22 g intravenous cannula. After confirmation
volume ETT (ID) of correct position 0.018 / 0.025 inch wire can be threaded
1 Neonates up to 5 kg 4 3.5 in cephalic direction. In patients with limited mouth opening
these wires can be retrieved using suction catheters.26
1½ Infant 5 – 10 kg 7 4.0
Subsequent tracheal intubation may be performed directly
2 Children 10 – 20 kg 10 4.5 over a wire or the guide wire may be used as a stylet,
passed through the suction port of larger fibreoptic
2.5 Children 20 – 30 kg 14 5.0
bronchoscope. The preferred approach is a fibreoptic with
3 Children > 30 kg 20 6.0 retrograde wire the advantages being.

Rigid nasendoscopic intubation - Higher success rate

Conventional laryngoscopy causes distortion of the - Faster intubation
supraglottic structures and creates difficult conditions for - Ability to insufflate oxygen through the suction port
the glottis to be seen. If the airway anatomy is not distorted, - No hanging up of ETT in glottis
glottis might be viewed with greater ease by an endoscope. - No need to rely or anatomic landmarks.
The 70 degree lateral illumination of the rigid endoscope
provides an excellent view of the larynx as soon as the
endoscope is passed till the uvula under direct vision
(fig. 4). Its oral introduction is atraumatic and does not
require additional skills for viewing the larynx. The field
of vision has suitable magnification with superior resolution
as compared to the frontal/end-on vision of the flexible
fibrescope.25 Separately introducing the endotracheal tube
and the endoscope permits the use of an endotracheal tube
of an appropriate size to be inserted into the glottis. The
dynamics of endotracheal tube insertion can be viewed
continuously on the screen till the whole process is
completed. In the event of the endotracheal tube slipping
or being caught at the glottis, it can be manipulated
under visual control to negotiate the glottic aperture
Fig. 5 : Endoscopic views with the rigid nasendoscope used
(fig. 5). Nevertheless, the technique requires co-ordination for tracheal intubation.
between both hands (one hand holds the endoscope and 1. View of the glottis from a distance 2. Closer view of the glottis
fixes the view of the glottis and the other manipulates 3. View of glottis and tube together 4. Lifting the epiglottis with the tube
the endotracheal tube) and one assistant, to stabilize the 5. Manipulation of the tube into glottis 6. Final position of the tube
head and pull the tongue out and to monitor the child as the
endoscopist has to constantly focus his attention on the Tactile technique
monitor screen.21 Nasal or oral intubation can be accomplished using
this technique. It depends upon palpating epiglottis by
Retrograde intubation second and third fingers inserted through child’s mouth.
This method has been used in anticipated or Once epiglottis is palpated the tube can be guided into the
unanticipated difficult airway after convention intubation glottis by the fingers.
strategies failed. In children cricothyroid membrane puncture
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN
Light wand
Light wand can be used for orotracheal or
nasotracheal intubation. Transillumination is used as a
guide for intubation. Tracheal placement results in well-
circumscribed bright glow where as oesophageal placement
results in diffuse glow. It is particularly useful in children
with limited movement of cervical spine and in patients
with limited mouth opening. With light wand for successful
intubation there is no need for alignment of oral pharyngeal
laryngeal axis. Ease of use is not related to difficulty in
direct laryngoscopy or Mallampattii score.
The basic construction of a light wand is a light
source at the end of a malleable stylet connected to power
source in handle.27 Light wands available for children include.
• Trach light – Accommodates ETT down to 2.5 mm
• Anaesthesia medical specialties – Accommodates ETT
down to 3.5 mm
• Aaron medical–Accommodates ETT down to 4.5 mm
A preselected tube of appropriate size is loaded
onto a lubricated light wand stylet. It is then bent to the
shape of hockey stick with head in neutral position. Light
wand is introduced in the midline, guided by transillumination
the light wand is advanced in midline till a well-
circumscribed glow appears below the level of thyroid
prominence. The key for successful placement is to stay in
midline and anteriorly.28 Once the light wand is in trachea
ETT is advanced off the light wand by railroad technique
and light wand removed carefully.
Complications of light wand include pharyngeal
trauma, arytenoid dislocation. The anatomic features that
make light wand intubation difficult include short thick
neck, large tongue and long floppy epiglottis.
Transtracheal jet ventilation (TTJV)
TTJV is the percutaneous insertion of a catheter into
the trachea through cricothyrorid membrane and ventilation
is achieved using jet ventilation. The source gas pressure
used for jet ventilation in adults is 50 psi and in children
it is 30 psi.29
TTJV is employed as an emergency airway. In
infants and children less than 5 yrs of age it has not
been recommended because of high incidence of vasovagal
events, subcutaneous emphysema, bilateral pneumothorax,
inadvertent placement into oesophagus and submucosal false
passage in trachea.
In infants and children cricoid and thyroid carriages
are soft and cricothyroid membrane is poorly defined.
Successful placement of catheter into infant trachea is also
more difficult to confirm.
305
Major limitation of TTJV is the need to maintain
patent airway cephalic to the catheter. If upper airway is
obstructed life threatening barotraumas occurs.
Cricothrotomy
It is procedure of choice for emergency access of
airway in all patients regardless of age, when conventional
means of airway control fails.30 In infants and in small
children the soft cartilages, ill defined cricothyroid
membrane makes this technique difficult.
Patient is positioned with optimal neck extension
with rolls under the shoulders, so that larynx comes
anteriorly. Cricothyriod membrane is identified. A horizontal
incision is made over the skin overlying to membrane with
11 size blade. Incision is deepened and the membrane is
punctured with tip of the blade pointing caudally to avoid
injury to the oesophagus and vocal cards. Using a curved
haemostat pointing caudally the entry point is widened and
ETT or tracheostomy tube is inserted into the trachea.
Percutaneous dilatational cricocthyrotomy (PDC) is
a variation of this technique, which uses Seldinger method
for insertion. Various kits are available (e.g. Pedia trake).
Only limited data are available of their use in paediatric
age group hence PDC is not recommended for paediatric
patients. Complications include bleeding, barotraumas and
oesophageal perforation.
Postoperative airway problems in children
Most commonly occurring post operative airway
problems in children include
1. Inability to tolerate extubation.
2. Laryngospasm.
3. Post intubation croup.
Other airways problems related to intubation are
mucosal lacerations in airway, arytenoids dislocation,
dental, temporomandibular joint trauma. They are rare with
properly performed laryngoscopy and intubation.
Inability to tolerate extubation
Inability to tolerate extubation may occur
commonly due to airway obstruction or due to hypoventilation
syndromes. It should be borne in mind that extubation has
a potential of leading to a reintubation. Reintubation may
become a problem in children in whom securing the airway
had been difficult or would now be difficult due to limited
access following surgery. For such children it is wise to
have a strategy that permits continued administration of
oxygen or provision for ventilation. This is achieved by use
of reintubation guides or tube exchangers. Catheters used
as reintubation guides in paediatric practice include Cooks
306 PG ISSUE : AIRWAY MANAGEMENT INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005

airway exchange catheter, Sheridan tracheal tube exchanger
and Cardiomed endotracheal ventilation catheter, the outer
diameters of which range from 2.0 – 5.8mm.
The identification of patients with a high risk for
post extubation complications is largely anecdotal. Children
undergoing laryngoscopy, uvulopalato-pharyngoplasty,
thyroid surgery, maxillofacial surgeries are more prone.
Extubation in fully awake condition and/or with reintubation
guides in situ avoids most of the catastrophic airway
complications in the early postoperative period.
Laryngospasm
The incidence of perioperative laryngospasm is about
18/1000 patients in the age group of 0–9 years of age.31
Infant’s 1–3 mo of age have highest incidence. The factors
associated with increased risk of laryngospasm are presence
of nasogastric tube, oral endoscopy surgeries, during
extubation. Inadequate anaesthetic depth is an important
factor contributing to laryngospasm during extubation done
in lighter planes. Laryngospasm occurs in response to glottis
or supraglottic mucosal stimulation involving apposition of
structures at three levels
1. Supraglottic folds.
2. False vocal cords.
3. True vocal cords.
Fink32 proposed a dual mechanism for closure of
larynx. Firstly, a shutter effect can be seen due to the
closure of the vocal cords, which in turn leads to increase
in translayrngeal pressure gradient. The soft tissues of the
supraglottic region become rounded and redundant due to
the shortening of thyrohyoid muscle, drawn into the laryngeal
inlet (Ball valve effect). Stridor gets manifested due to
intermittent closure of glottis.
Prevention
Prevention is the ideal remedy. Patients with known
risk factors may be given intravenous lignocaine 2 mgkg-1
given slowly over a period of 30 sec, one min before
extubation. To derive any benefit from lignocaine
administration, extubation should be done before signs of
swallowing activity appear.33 Another preventive measure
they may be prone to hypoventilation or respiratory
obstruction.
Management
Incomplete obstruction is associated with audible
inspiratory or expiratory sound, if obstruction progresses
tracheal tug, paradoxical respiratory movements of chest
and abdomen develop. Once complete obstruction develops
audible sounds cease. One must remember that the primary
concern during laryngospasm is oxygenation of the patient
and not intubation. Several therapeutic manoeuvres have
been suggested.
1. Removal the irritant stimuli like debris from larynx.
2. Forward jaw thrust at the temporomandibular joint by
applying pressure on the ascending rami of mandible.
This manoeuvre lengthens the thyrohyoid muscle and
unfolds the soft supraglottic tissue.
3. Facilitate ventilation by applying gentle continuous
positive airway pressure with 100% oxygen by a tight
feeling face mask.
Any measure of laryngoscopy and intubation attempt
may turn incomplete obstruction to complete one. If these
methods do not help and if the child remains hypoxic Succinyl
choline 0.5 mgkg-1 relieves laryngospasm. In the event of
bradycardia, atropine should be administered concomitantly
ensuring adequate oxygenation with 100% oxygen through a
tight fitting face mask.
Post intubation croup
It is caused by inflammation of subglottic region due
to mechanical irritation of ETT. Contribution factors are
age (1–4 years), trauma during intubation, a tight fitting
ETT with no leak at 25 – 40 cm H2O, surgery in neck
region, children with previous history of croup and long
duration of intubation (more than 1 hour).
Table - 5 : Downes scoring system
0 1 2
Stridor None Inspiration Inspiration & expiration
Cough None Hoarse cry Bark

proposed is application of local anaesthetic agents to the Retraction & None Flaring & suprasternal Flaring, suprasternal,
supraglottic mucosa. Lee and Downes34 suggested. “The nasal flaring retraction subcostal, intercostal
retractions.
infant or child before tracheal extubation should open his
eyes or mouth spontaneously, move all extremities vigorously Cyanosis None On air On 40% oxygen
and resume a normal breathing pattern after a cough.” to
Inspiratory Normal Harsh with rhonchi Delayed
prevent laryngospasm. Extubation under surgical depth of breath sound
anaesthesia is advocated by some; however, no data are
available to support this view. This practice may lead to Clinical features : Stridor occurs soon after
premature transfer of children to the recovery room where extubation (within 1 hr). Maximum intensity is within 4 h
KUNDRA, KRISHNAN : AIRWAY MANAGEMENT IN CHILDREN
and complete resolution occurs within 24 hr. In severe
forms, subglottic oedema appears as a “steeple sign” in
chest radiograph. A scoring system for post extubation croup
is described by Downes and Raphaely35 used for classifying
croup into mild, moderate and severe (table 5). Normal
score is 0 and the maximum score is 10, patient with a
score of 7 or more suggests prophylactic artificial ventilation
(table 5).
Treatment
1. Mild: Humidification, oxygen inhalation, hydration
2. Moderate: Add epinephrine nebulization36 (0.25-0.5 ml
racemic epinephrine in 2.5 ml normal saline)
3. Severe: Repeat epinephrine nebulization up to three
times. If score > 7, consider artificial ventilation
References
1. Kundra P, A Vasudevan, M Ravishankar. Video assisted fibreoptic intubation
for temporomandibular ankylosis. Ped Anesth 2005. Accepted for
publication (4.6.2005).
2. Eckenhoff JE. Some anatomic considerations of infants influencing
endotracheal anesthesia. Anesthesiology 1951; 12: 401.
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