Be prepared for the unexpected!

The difficult pediatric airway continues to fascinate anesthesiologist as illustrated by the case report by Varshney and Jain[1] in this issue. They can be overcome with great clinical skills in the face of limited resources, improvisation, and sometimes with a little fortune.

Airway problems remain a significant cause for perioperative cardiac arrests in children, second only to cardiovascular causes.[2] Risk factors include age of the child, underlying pre-existing disease, experience of the anesthesiologist, and choice of technique.[3] Mortality can approximate zero in some centers[4] but still exists even in resource rich countries.[5]

The current case report raises two questions: What is an acceptable approach to this expected and admittedly rare difficult airway problem and what is the optimal approach including the potential rescue strategies? The authors illustrate their approach and successful management. Maintenance of spontaneous respiration is maintained until tracheal intubation is secured and skilled assistance from an experienced anesthesiologist is provided. The second question remains largely unanswered and deserves further exploration.

What would be the optimal approach for the management of this patient?

Clearly, this has to be seen in the context of available resources. However, patients with an expected difficult pediatric airway belong in the hands of the experienced pediatric anesthesiologist. Options considered and positively excluded by the authors were awake intubation, trachlight, retrograde intubation, and (awake) tracheostomy. No information is available if rigid bronchoscopy or cardiopulmonary bypass was at their disposal. Worryingly, however, flexible fiberoptic intubation was not available for this set-up from the start or even available at all. Therefore, fiberoptic intubation via the oral or nasal route or via a laryngeal mask would not have been possible if their initial devised plan would have failed. “Loosing the airway” in this patient following inhalational induction could have resulted in a major catastrophe such as hypoxic injury and death. Is the “Try to go as far as possible without loosing the option of a wake-up” really appropriate? Should and could this patient have been better prepared? Were they really best prepared for and equipped for the unexpected and sudden deterioration in this elective difficult pediatric airway? The answer is probably “no.”

Pediatric airway problems have 2 principal causes: (1) Functional and (2) anatomical/mechanical airway obstructions. Functional airway problems such as laryngospasm, bronchospasm, and insufficient depth of anesthesia as well as opioid-induced muscle rigidity are common and frequently occur unexpectedly in the otherwise healthy child.[6] Anatomical obstructions (large tonsils, adenoids, secretions, or other foreign bodies) are also common but are easily overcome with good basic airway maneuvers and the use of oronasopharyngeal airways. A simple, concise, forward only, locally optimized, and frequently practiced strategy is essential to ensure oxygenation and ventilation at all times.[7] Avoidance of hypoxia during airway instrumentation attempts, sometimes facilitated by using a supraglottic airway, has to be the primary goal to prevent significant anesthesia-related morbidity and mortality in this common but “unexpected” situation.

In contrast to the “unexpected” pediatric airway problems, the “suspected” (the acutely impaired normal) and the “expected” difficult airway problems require experience, expertise, and appropriate equipment, facilities, and support. Specialist surgical support should be ready at induction of anesthesia if any doubts about the ability to ventilate the child exist. A clear rescue strategy needs to be defined prior to embarking on the child with a suspected or expected difficult airway.

This case report illustrates the skill and expertise required to successfully manage a child with an expected difficult airway in very specific circumstances. However, the lack of essential equipment (and perhaps skill how to use this) and planning for the “unexpected” prior to induction of anesthesia makes it difficult to understand why this patient was not referred to a center that does.

The fortuitous outcome for this patient is likely due to the avoidance of unexpected problems. Be prepared!