Scary Airways: What Have We Learned?Dawn M. Sweeney, M.D.Associate Professor of Anesthesiology and PediatricsUniversity of Rochester Medical Center

Conflicts of Interest None

Goals and Objectives recognize that the signs and symptoms of

airway foreign bodies may be subtle discuss the incidence of airway

anatomical issues in children with congenital heart disease

describe instances when a different intraoperative approach might be needed

What is a Scary Airway? Any airway that makes you stop and think

about what you did, and about what you did not do!

It is not necessarily only an airway for which things did not go well.

It is possible (and often preferable)to be scared of an airway even if everything goes well.

What is the purpose of a Scary Airway? To keep us from getting complacent To keep us searching for new and better

ways to care for children with scary airways

To keep us motivated to maintain and better our skills for managing difficult airways.

Anecdote 1 The case of the persistent mother

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

Anecdote 1 You are on call, and currently finishing a

supracondylar fracture. There are 2 or 3 more supracondylar fractures in the ED.

The ENT resident approaches you to tell you that there is a 9 month old in the ED with a possible airway foreign body, but that the possibility is low. The baby looks fine, and the ENT team thinks it will be fine to wait until after the fracture cases are finished. The choking event occurred on Thursday, and it is now Monday evening.

What Do You Want to Do? Will you wait until the fractures are done? Will you call in another team? Do you have another plan in mind? Do you want more information? Do you trust the ENT resident’s assessment

of the situation?

Examine the Baby The baby is brought to preop holding to be

seen when we finish the current fracture. She is quiet, breathing quietly without

apparent increased work of breathing Her oxygen saturations are in the mid to high

90’s in room air Mother says she sounds hoarse when

vocalizing, and that the pediatrician had seen the baby earlier in the day and said she had croup.

What Next? While you are speaking to the mother, the

baby suddenly flops forward, bangs her head on the wooden arm of the chair, then sits back up, shakes her head a little, and continues to sit placidly in her mother’s arms.

What do you think about this?

And Again! A couple of minutes later, the flopping

occurs again. The baby is again not distressed by hitting her head on the wooden chair arm.

What is going on?

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

What Did We Find? The corner of a McDonald’s ketchup

packet lodged just below and between her vocal cords.

There was significant granulation tissue in this area resulting in a 2 mm airway.

What Did We Learn? The signs of an airway foreign body can

be very subtle, even in the presence of significant airway obstruction.

The ENT team was pretty convinced that we would find only signs of croup and no FB.

If her mother had listened to the pediatrician, this child might have died at home.

Anecdote 2 It’s always at 5:00 PM on a Friday!

I have an Interesting Case It is 5:00 PM on a Friday, and a colleague

calls you and asks if you are still at the hospital.

He has an interesting airway case, and would like you come and look at the baby.

Anecdote 2 The patient is a 49 day old male infant

with progressive enlargement of his tongue since birth.

He has no respiratory symptoms, but has been losing weight due to poor feeding.

Physical Exam There is a tense sublingual mass that has

displaced the tongue up towards the hard palate.

A CT scan shows a 2.4 cm by 2 cm cystic mass arising from the base of the tongue.

The baby is thin, but is not in any respiratory distress.

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

What Did We Do? There was plenty of room posteriorly in the

mouth, so we placed an LMA after letting him suck on some viscous lidocaine and induced anesthesia through the LMA.

The mass was marsupialized. The baby had no problems during

emergence or recovery. He was discharged to home the next day.

What Did We Learn? Sometimes it is not as bad as it looks!

Anecdote 3 You look at the schedule and discover

that you are scheduled for a craniosynostosis repair the following day.

You then find out the child has Antley-Bixler Syndrome.

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

Antley-Bixler Syndrome Difficult to see in photo, but the head has

a very short A-P distance, and is shaped somewhat like an M& M.

These children can have multiple craniofacial abnormalities including choanal atresia or stenosis.

They can be extremely difficult to intubate to mask ventilate and intubate.

Anecdote 3 You read further in the chart and discover

that the child has a tracheostomy.

Preoperative Evaluation You speak with the parents who state that

there is nothing new going on with the baby. He has no new respiratory problems or increase in secretions.

His physical exam reveals slightly coarse breath sounds, but good air entry with no wheezing or rales present.

What Next? You take the baby to the OR, induce

anesthesia with the baby breathing spontaneously through his uncuffed Shileytracheostomy.

You spend the 90 minutes obtaining venous and arterial access (these patients also have radial and foot anomalies).

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

What About the Airway? You decide to replace the tracheostomy

with a cuffed endotracheal tube for the procedure as there is considerable leaking around the tracheostomy.

You give a dose of pancuronium, remove the tracheostomy, place the ETT, inflate the cuff, and you are immediately unable to ventilate this child.

Really? You try multiple maneuvers, including

replacing the tracheostomy, replacing the ETT, calling for an ENT surgeon, worrying about a false passage, continuing to try to ventilate and oxygenate.

The baby has a cardiac arrest, PALS is initiated.

Now What? Somehow the baby actually has ROSC. Not

clear how we managed that in the face of limited oxygenation and ventilation.

The ENT surgeon arrives and prepares to perform bronchoscopy.

Bronchoscopy reveals bilateral mainstembronchi granulomas and demonstrates ball-valve effect with positive pressure ventilation.

Case Cancelled The ENT surgeon removes the granulomas,

and the craniosynostosis repair is cancelled. The baby recovers from the anesthesia

without event, and is sent to the PICU for observation overnight.

In speaking with the parents postoperatively, they share with you that they had replaced the tracheostomy multiple times over the weekend due to suspicion that it was plugged, but that it had not been found to be plugged. (It would have been nice to be told about this preoperatively.)

What Did We Learn? That sometimes things are much more

difficult than they look. Sometimes parents don’t mention

important issues. (for a variety of reasons)

Anecdote 4 You are scheduled to anesthetize a 4

month old with “pink” Tetralogy of Fallot. She has developed tachypnea which is

being attributed to possible pulmonary over circulation and congestive heart failure.

She is tachypneic with feeding in particular, but is otherwise doing well.

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

Off to the OR You bring the baby to the OR, perform an

inhalation induction without incident, and a peripheral IV is placed.

You give a dose of pancuronium, and prepare to intubate.

Your resident is unable to pass a 3.5 ETT. You are then also unable to pass a 3.5 ETT, a

3.0 ETT, or a 2.5 ETT. In each case, you are able to pass the ETT a

few millimeters below the vocal cords, but no further.

What Now? You call the pediatric ENT surgeon (yes, there

is only one)who is at his clinic (a couple of miles from the hospital).

You describe the situation, and tell him you think it might be complete tracheal rings.

He says that maybe it is only subglottic stenosis, cancels his clinic patients, and comes over to perform bronchoscopy and a cricoid split.

What Did We Find? Complete tracheal rings We woke the patient up without an ETT,

took her to the PICU to recover overnight, and then discharged her in the morning.

She subsequently went to another institution for slide tracheoplasty and incidental TOF repair.

What Did We Learn? It is not always the heart!

Tracheal Defects and Congenital Heart Defects Can Occur Together Both patients I have seen with complete

rings had TOF Up to 11% of patients with TOF may have

a tracheal abnormality Should babies with TOF be screened for

tracheal anomalies?Starc M, Berdon WE, Starc TJ. Undiagnosed primary tracheal stenosis in tetralogy of Fallot: complete tracheal rings with a low carina. Pediatr Radiol. 2014 Mar; 44(3):362-3.

How Can We Diagnose This Before Going to the OR? It is currently unclear if we should be

screening babies with congenital heart defects for complete tracheal rings.

For pulmonary artery sling, this should really be considered.

Should babies with Tetralogy of Fallot be screened since 11% may have tracheal rings?

Sweeney, Dawn, MD Scary Airways: What Have We Learned?

Heart Defects and tracheal Stenosis 30% of tracheal stenosis is associated with

pulmonary artery sling (I have never seen this)

The left pulmonary artery arises from the right pulmonary artery

This can either compress a normal trachea or be associated with tracheal rings

Other Cardiac Anomalies Associated with Tracheal Stenosis 60% of babies with complete tracheal

rings have congenital heart defects. AV Canal, VSD, TOF, TAPVR, and ASD

have all been seen with complete tracheal rings.

20% of babies with complete tracheal rings have Trisomy 21.

Thank you!

Sweeney, Dawn, MD Scary Airways: What Have We Learned?