Managing the difficult airway in the syndromic child
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Tags: Paediatric Surgery, Difficult airway,
Abstract
Notes
Annotations
(8/10/2022, 12:51:48 AM)
“Besides the routine general preoperative assessment, the clinical evaluation of the syndromic child with a potentially difficult airway should focus on signs and symptoms of
- airway obstruction
- including a history of apnoea episodes and daytime somnolence and also evidence of noisy breathing, stridor, snoring, and increased work of breathing.
- Owing to the anatomical changes, ../../Knowledge/Medicine/obstructive sleep apnoea syndrome is often present in these patients.
The clinical examination should include a review of
- dentition
- e.g. loose teeth, overbite,
- extent of mouth opening,
- head–neck mobility,
- facial anomalies (micro- or retrognathia, mid-face hypoplasia),
- anomalies of the palate and mandibular floor, and
- assessment of the thyromental distance.” Go to annotation (Raj and Luginbuehl, 2015, p. 7)
Apert syndrome (acrocephalosyndactyly)
This autosomal-dominant disorder is caused by a single-gene defect on chromosome 10 and occurs in 1:100 000 live births. It affects the first branchial arch and results in malformations of the skull, face, hands, and feet.” Go to annotation (Raj and Luginbuehl, 2015, p. 11)
“Issues for airway management The premature fusion of the coronal suture and cranial base sutures leads to hypertelorism, while the reduction in antero-posterior and downward growth of the nasopharyngeal airway results in mid-face hypoplasia with narrow nasopharyngeal passages and variable degree of choanal stenosis, a high, arched palate, which is often covered with excessive soft tissue, all contributing to obstruction of air flow. These changes may progress with age making airway management, particularly facemask ventilation more difficult. Fused cervical vertebrae are found in about two-thirds of patients (mainly at C5 –6 and less commonly at the C3 –4 level), and depending on the limitation of neck mobility may cause problems with intubation. The aforementioned findings contribute to OSAS potentially further aggravated by narrowing of the trachea secondary to fused tracheal rings (bamboo trachea), which might require the use of a smaller than anticipated tracheal tube. The fusion of tracheal rings leads to stiffening of the trachea, thereby affecting the ability to narrow and create high-velocity airflow to clear secretions. The accumulation of secretions could produce ‘monophonic’ wheezing sounds. Respiratory complications in a retrospective review occurred in 10% of anaesthetic procedures. The exact reason for the increased incidence of complications in these patients is not known, but laryngo- or tracheomalacia from previous tracheostomy combined with increased tracheobronchial secretions and their limited clearance may be contributing factors. Most respiratory complications were managed with bronchodilators, increasing depth of anaesthesia, or both.
Not surprisingly, patients with pre-existing upper respiratory tract infections were more likely to experience respiratory complications. Given the high risk of airway complications resulting from upper respiratory tract infection alone in these patients, it seems prudent to postpone elective procedures until symptoms related to airway secretions and infections have been optimized. Direct laryngoscopy view can worsen after mid-face advancement surgery which is commonly carried out for cosmetic reasons. Limited mouth opening due to fibrosis or mechanical impingement of the temporalis muscle after operation can occasionally be a contributing factor.” Go to annotation (Raj and Luginbuehl, 2015, p. 11)