Pediatric Difficult Airway Management (DAM) : Cannot Intubate, Cannot Ventilate (CICV)

Abstract

  A horrifying CICV scenario is fortunately extremely rare in pediatric anesthesia practice. Very few anesthetists thus have previous experience to handle airway emergencies in children. In a CICV situation, supraglottic airways such as Laryngeal Masks may occasionally work. If these devices fail to provide ventilation/oxygenation, rapid tracheal access is required to restore oxygenation. However, the pediatric cricothyroid membrane is small, particularly in neonates, and identifying its position can be difficult in a hypoxic, struggling child. Due to higher oxygen consumption per body weight as well as smaller functional residual capacity of the lungs compared to adults, children desaturate rapidly once ventilation becomes impossible. Although it is usually quicker to place a catheter via the cricothyroid membrane than to perform tracheostomy, the time required for needle cricothyrotomy may be too long to prevent hypoxic damage. Transtracheal jet ventilation (TTJV) is not a technique without risks. It is important to confirm exhalation via a narrowed upper airway between jet ventilation, otherwise serious barotrauma easily occurs. Use of a kink-resistant catheter is highly recommended and knowledge of the correct driving pressure of the TTJV apparatus is essential. Considering the anatomical and physiological restrictions in children, decision-making is of paramount importance, more than it is in adult DAM. In pediatric Difficult Airway Management, anesthetists should therefore more readily abandon persistent intubation attempts and to consider waking up the child from anesthesia while mask ventilation is still maintained.