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BACKGROUND: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. METHODS: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. FINDINGS: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p

BackgroundDifficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation.MethodsWe queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed.ResultsThe incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening.ConclusionsCertain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Background: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first‐attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first‐attempt success rate. Methods: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012–03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. Results: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First‐attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p =.478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p =.959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: −0.7, 0.7; p =.999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: −0.5, 0.5; p =.999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p =.07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p =.185). Conclusions: Presence of syndrome was not associated with lower first‐attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Background: Direct laryngoscopy and intubation are often difficult in children with Robin Sequence. Previous research characterizing anatomic airway differences has focused on parameters influencing airway patency; there is a paucity of data pertaining to intubation trajectories and depth. Such information could impact airway management approaches and decrease the incidence of endotracheal tube malpositioning. Aim: The study goal was to examine whether longitudinal airway parameters pertaining to intubation are different in children with Robin Sequence compared with age‐matched controls. Method: This case‐control study compared patients with RS <4 years of age who had computed tomography scans of the head and neck to age‐ and sex‐matched controls. Measurements were made of the nasopharynx, oropharynx, hypopharynx, tongue, hyoid, and the front teeth to vocal cord, nares to vocal cord, and nasion‐basion distances. Statistical analysis was performed using multiple ANCOVA models with the categorical predictor of Robin Sequence vs control and potential covariates including subject height/length, weight, and age. Results: Thirty‐three patients with Robin Sequence and 33 control subjects were included. After controlling for subject height/length, mean front teeth to vocal cord distance was 1.2 cm longer (95% CI: 0.9 to 1.6 cm, P <.001) and mean nares to vocal cord distance was 0.8 cm longer (95% CI: 0.4 to 1.2 cm, P <.001) in patients with Robin Sequence than in controls. The tongue was positioned on average 0.5 cm higher (95% CI: 0.3 to 0.8, P <.001) and 0.9 cm more posterior (95% CI: 0.6 to 1.0 cm, P <.001) in cases than in controls. Moreover, in patients with Robin Sequence, the hyoid was positioned on average 0.5 cm more inferiorly (95% CI: 0.2 to 0.8 cm, P <.001) and 0.2 cm more posteriorly (95% CI: 0.1 to 0.4 cm, P <.01) than controls. Conclusion: In patients with Robin Sequence under 4 years of age, the mean front teeth to vocal cord distance was found to be 1.2 cm longer while the mean nares to vocal cord distance was found to be 0.8 cm longer controlling for subject length. Clinicians should account for these differences when selecting and placing endotracheal tubes, particularly those with a preformed bend. [ABSTRACT FROM AUTHOR]

Background The aim of the study was to examine different brands of preformed oral and nasal endotracheal tubes ( ETT) and to assess whether the bend placement gave acceptable guidance for ETT depth positioning in children. Methods The distance from the vertex of the bend to the tip (bend-to-tip distance) of seven brands of preformed oral and nasal ETTs were measured. Front teeth-to-carina ( FTC) and nares-to-carina ( NC) distance data from orally (0-19 years) and nasally (0-8 years) intubated children were used to assess the risk of endobronchial intubation if a preformed ETT had been placed with its bend at the front teeth or nares. Results While the bend-to-tip distance of a cuffed oral preformed ETT only differed by 0-1 cm from a same size ETT from another brand, uncuffed oral ETTs differed by 0-4 cm. The bend-to-tip distance of cuffed and uncuffed ETTs of the same brand and size differed by 0-3 cm. Had preformed cuffed oral ETTs been placed with their bends at the front teeth in children of the FTC reference group, endobronchial intubation would have occurred in 0-27% of the patients, depending on the size and brand of the used ETT. In contrast to oral ETTs, the bend-to-tip distance of cuffed nasal ETTs differed more (0-5.5 cm) between brands, and uncuffed nasal ETTs less (0-3 cm). Also, the bend-to-tip distance of a cuffed nasal ETT was consistently greater (2-9 cm) than that of a same brand and size nasal uncuffed ETT. Had a preformed cuffed nasal ETT been placed with its bend at the nares in the NC reference group, 50-100% of the patients would have been endobronchially intubated. Conclusion The bend-to-tip distance of preformed ETTs varies between brands, especially for nasal tubes. Some preformed tubes are not well suited for routine use in children. There is a high risk for accidental endobronchial intubation if a cuffed preformed ETT is positioned with its bend at the front teeth or nares in a young child. ETT tube tip position needs to be carefully controlled when a preformed ETT is used in a child. [ABSTRACT FROM AUTHOR]

Background Knowledge of the normal nares-to-carina ( NC) distance might prevent accidental bronchial intubation and be helpful when designing preformed endotracheal tubes ( ETT). Objective The aim was to measure NC distance and to examine whether a height/length-based 'modified Morgan formula' would give useful guidance for nasotracheal ETT depth positioning. Methods Two groups were studied. A younger group consisted of nasally intubated postoperative patients. In these, NC distance was obtained as the sum of ETT length and the distance from the ETT tip to the carina, as measured from an anteroposterior chest X-ray. An older group consisted of children who had undergone computerized tomography ( CT) examination including head, neck, and chest. In these, NC was measured directly from the CT image. The modified Morgan formula was derived from the NC vs height/length relationship. Results Nares-to-carina distance was best predicted by a linear equation based on patient height. The equation in the younger group (1 day-8 years, n = 57) was: NC (cm) = 0.14 × height + 5.8, R2 = 0.90, and in the older group (2.1-20 years, n = 45): NC (cm) = 0.15 × height + 3.4, R2 = 0.93. The equation for the groups combined ( n = 102) was: NC (cm) = 0.14 × height + 6.2, R2 = 0.97. Based on the latter equation, a modified Morgan formula was identified as: ETT position at nares in cm = 0.12 × height + 5. If the ETT had been placed as calculated by this formula, the ETT tip would have been at 85 + 5% (mean ± sd) of NC distance, and the ETT tip-to-carina distance would have been 3.1 ± 1.1 cm (range 0-6.6). Bronchial intubation would not have occurred in any child, but a comparison to tracheal length measurements indicates that ETT tip position could be too proximal in some children. Conclusion The study confirms previous reports: NC distance can be well predicted from height/length. A modified Morgan formula might decrease the risk for accidental endobronchial intubation in infants and children, but ETT position need to be confirmed by auscultation or other verification. [ABSTRACT FROM AUTHOR]