Anaes · Paediatric anaesthesia
Difficult and syndromic paediatric airway: anticipation, syndromes, and algorithms
Also known as Syndromic paediatric airway · Pierre Robin anaesthesia · APAGBI DAS paediatric difficult airway
Exam-exhaustive anticipated difficult paediatric airway: syndrome-specific anatomy (Pierre Robin, Treacher Collins, mucopolysaccharidoses, Down syndrome, Goldenhar), APAGBI/DAS unanticipated difficult intubation principles, equipment, spontaneous ventilation strategies, CICO pathways, and shared decision planning for fellowship exams.
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Target exams
Red flags
- Mucopolysaccharidoses: progressive catastrophic airways — most experienced team.
- Pierre Robin: micrognathia and glossoptosis — prone/lateral positioning may help.
- Down syndrome: atlantoaxial instability risk — careful neck handling.
- Do not burn bridges with repeated blind attempts.
- Have a surgical airway plan sized for age before induction of the anticipated difficult airway.
Meet the patient
An 18-month-old with Hurler syndrome is posted for dental extractions under general anaesthesia (taught vignette). Last year's chart reads "easy intubation, grade 1". The examiner's question is the one that catches the over-confident registrar: is last year's airway still this year's airway?[1]
It is not. Mucopolysaccharidoses are progressive (taught), and the case that looked easy is exactly the one that catastrophically fails once glycosaminoglycan deposition has thickened the tongue and narrowed the glottis. The two questions that frame every syndromic airway follow from that: can I keep oxygen going at every step? and who is in the room with me before I give the first drug?[1]
References7ShowHide
- [1]Black AE, Flynn PE, Smith HL, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth, 2015.PMID 25684039
- [2]Flick RP, Wilder RT, Pieper SF, et al. Risk factors for laryngospasm in children during general anesthesia. Paediatr Anaesth, 2008.PMID 18315633
- [3]Shi F, Xiao Y, Xiong W, Zhou Q, Huang X Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth, 2016.PMID 26296534
- [4]Mihara T, Uchimoto K, Morita S, Goto T The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis Anaesthesia, 2014.PMID 24992191
- [5]Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial Lancet, 2016.PMID 26507180
- [6]McCann ME, de Graaff JC, Dorris L, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial Lancet, 2019.PMID 30782342
- [7]Weiss M, Engelhardt T Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth, 2010.PMID 20337959