ADVANCED AIRWAY TECHNIQUES

When basic airway maneuvers and adjuncts (OPA/NPA, bag-mask ventilation) are insufficient to maintain adequate ventilation, advanced airway techniques are required. These interventions provide a secure, reliable airway, allowing for controlled oxygenation, ventilation, and airway protection.

Advanced airway management is particularly critical in pediatric patients, who are prone to airway obstruction and rapid oxygen desaturation.

 

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LARYNGEAL MASK AIRWAY (LMA) INSERTION

The Laryngeal Mask Airway (LMA) is a supraglottic airway device that is inserted into the oropharynx and sits above the glottic opening. Unlike an endotracheal tube (ETT), the LMA does not pass through the vocal cords.

When to Use an LMA:
Difficult or failed intubation (LMA serves as a backup airway).
Short-term airway management when intubation is not immediately required.
During procedures requiring general anesthesia.

Steps for LMA Insertion:

1. Choose the correct size:
   • Infants (≤5 kg): Size 1
   • Infants (5-10 kg): Size 1.5
   • Children (10-20 kg): Size 2
   • Children (20-30 kg): Size 2.5
   • Children (30-50 kg): Size 3
2. Deflate the cuff completely and lubricate the posterior surface.
3. Position the patient in the sniffing position (unless cervical spine injury is suspected).
4. Insert the LMA following the natural curvature of the airway until resistance is met.
5. Inflate the cuff with the recommended volume of air (based on the size).
6. Check for proper placement by auscultating breath sounds and monitoring chest rise.

Precautions:

• Not a definitive airway—aspiration risk remains.
• Not effective in complete upper airway obstruction (e.g., foreign body, severe laryngospasm).
• Should not be used in patients with high airway resistance (e.g., severe asthma, ARDS).

Clinical Application:
Useful as a temporary rescue airway in difficult intubations.
Can be used as a bridge to endotracheal intubation if needed.

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ENDOTRACHEAL INTUBATION (ET) FOR PEDIATRICS

Endotracheal intubation (ETI) is the gold standard for securing an airway, allowing for mechanical ventilation, oxygenation, and airway protection.

When to Perform Endotracheal Intubation:
Respiratory failure (inability to maintain oxygenation/ventilation).
Airway protection (e.g., altered mental status, severe trauma).
Cardiac arrest requiring prolonged ventilation.
Severe shock or multi-organ failure requiring controlled respiration.

Steps for Pediatric Endotracheal Intubation:

1. Prepare Equipment:

   • Select the correct tube size using the formula:
     Uncuffed ETT: (Age in years ÷ 4) + 4
     Cuffed ETT: (Age in years ÷ 4) + 3.5
   • Confirm the correct depth: (ETT size × 3 = approximate depth in cm at lips).
   • Ensure suction, bag-mask ventilation, and backup airway devices (LMA) are available.

2. Positioning:

   • Sniffing position (head extended, neck flexed) for optimal visualization.
   • If cervical spine injury is suspected, use manual inline stabilization (no head movement).

3. Preoxygenate:

   • 100% oxygen for at least 30-60 seconds before intubation.

4. Perform Rapid Sequence Intubation (RSI) if indicated:

   • Consider sedation and neuromuscular blockade for controlled intubation.

5. Intubation Procedure:

   • Insert the laryngoscope blade (Miller for neonates/infants, Mac for older children).
   • Identify landmarks (vocal cords, glottis opening).
   • Advance the ETT through the vocal cords.

6. Confirm Placement:

   • Capnography (gold standard) – End-Tidal CO₂ should be present.
   • Auscultation – Listen for bilateral breath sounds.
   • Chest rise – Ensure symmetrical movement.
   • No gastric inflation – Check that air is not entering the stomach.

7. Secure the Tube:

   • Tape or use an ET tube holder.
   • Obtain a chest X-ray to confirm placement (tip should be at T2-T3 level).

Precautions:

• DO NOT attempt multiple intubations—prolonged attempts can cause hypoxia and bradycardia.
• Use the correct tube size—oversized tubes increase airway trauma, undersized tubes cause leaks.
• Always have a backup plan (LMA, BMV) in case of failed intubation.

Clinical Application:
Definitive airway in critical pediatric patients.
Used when long-term mechanical ventilation is required.

 

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CHOOSING THE RIGHT AIRWAY MANAGEMENT TECHNIQUE

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SUMMARY: WHY ADVANCED AIRWAY MANAGEMENT MATTERS

LMA is a quick, supraglottic rescue airway that is easy to insert but does not protect against aspiration.
Endotracheal intubation (ETI) provides a definitive airway, ensuring full control of oxygenation and ventilation.

Takeaway: Advanced airway management must be performed quickly and correctly to prevent hypoxia and cardiac arrest. Knowing when to use LMA vs. ETI can make the difference between life and death.