Difficult paediatric airway and emergency front-of-neck access — formative SAQs

SAQ 1 (10 marks)

A 2-year-old boy with Pierre Robin sequence is brought to the emergency department with increasing respiratory distress and reduced conscious level after a prolonged seizure. The team plans to intubate. He has a documented history of difficult intubation at his cleft repair. [2] [3]

1. Explain why this airway is anticipated-difficult and how you would prepare. (3) [2]
2. Outline the recognise-oxygenate-escalate-rescue sequence you would follow at intubation. (4) [1]
3. Describe how you would respond if the first laryngoscopy fails. (3) [1]

Model answer — SAQ 1

(1) Anticipated difficulty and preparation (3). This airway is anticipated-difficult because of the micrognathia and small mandible of Pierre Robin sequence, which make the larynx high and anterior and the view poor, and because of the documented previous difficult intubation, which is the single strongest predictor of future difficulty. I would treat this as a senior-led planned event: assemble an experienced anaesthetist and ENT surgeon, the difficult-airway trolley, a videolaryngoscope, and a correctly sized supraglottic airway open and ready, and I would consider an awake or inhalational technique rather than abolishing airway tone with a full rapid-sequence induction, because a syndromic child may obstruct completely once sedated. [2] [3]

(2) Recognise-oxygenate-escalate-rescue (4). I recognise the anticipated difficulty before induction and prepare accordingly. I position the child in the sniffing position with a shoulder roll as needed, preoxygenate with high-flow oxygen for as long as tolerated, and keep oxygen on at every step because an infant can desaturate within a minute. I give one optimised best attempt with the right blade, external laryngeal manipulation and a skilled assistant. At the first failure I escalate by calling for the most senior airway help, limit further attempts to avoid traumatising the cricoid, and insert a supraglottic airway to oxygenate. The rescue rung is emergency front-of-neck access, reserved only for cannot-intubate-cannot-oxygenate. [1]

(3) Response to failed first laryngoscopy (3). I stop repeating the same direct laryngoscopy, because each attempt traumatises and swells the cricoid — the narrowest point of the child's airway — and can turn a difficult airway into an impossible one. I call for the most senior anaesthetist and ENT surgeon immediately, switch to the rescue sequence by inserting a supraglottic airway to oxygenate, and keep the child oxygenated throughout. If the supraglottic airway works I have time to wake an elective child or proceed with a resuscitation; if it fails to oxygenate too, I declare cannot-intubate-cannot-oxygenate and prepare for emergency front-of-neck access. [1]

SAQ 2 (10 marks)

A 6-month-old infant with bacterial tracheitis deteriorates during an attempted intubation. After the third direct laryngoscopy attempt the view is worsening, the saturations are falling, the heart rate has dropped to 60, and neither mask ventilation nor a supraglottic airway restores oxygenation. [1] [3]

1. What is the diagnosis and why is it a peri-arrest emergency? (4) [1]
2. Outline your immediate management. (3) [4]
3. Explain the pitfalls that led here and how to avoid them. (3) [2]

Model answer — SAQ 2

(1) Diagnosis and why it is peri-arrest (4). This is cannot-intubate-cannot-oxygenate: after failed intubation the team cannot intubate and cannot oxygenate by mask or supraglottic airway. It is a peri-arrest emergency because the infant has no further oxygen reserve — the bradycardia to 60 with falling saturation is the pre-terminal vagal and hypoxic response — and without immediate restoration of oxygenation the child will arrest within seconds to a minute. The repeated laryngoscopy has traumatised and swollen the cricoid, worsening an already inflamed airway. [1] [3]

(2) Immediate management (3). I declare cannot-intubate-cannot-oxygenate out loud and perform emergency front-of-neck access without delay using the scalpel-bougie technique — a transverse stab through the cricothyroid membrane, rotation to open the tract, passage of a bougie, and railroad of a cuffed tube — while a colleague runs the resuscitation in parallel, treating the bradycardia with oxygenation and, if the child arrests, adrenaline per the cardiac arrest protocol. I continue high-flow oxygen at the face throughout and summon the most senior airway and surgical help. [4]

(3) Pitfalls and avoidance (3). The dominant pitfall was repeating a failing direct laryngoscopy — three attempts traumatised and swelled the inflamed cricoid and turned difficulty into impossibility — and ignoring the bradycardia and falling saturation as stop signals. The avoidable errors were not calling for the most senior help at the first failure, and not moving earlier to supraglottic-airway rescue before the child reached cannot-oxygenate. The teaching is to anticipate the difficult and inflamed airway, give one best attempt, call help early, and rescue with the supraglottic airway before the front-of-neck step is ever needed. [2]