1. Dr Moataz Abdelrahman
Consultant Paediatric Anaesthetist
Central Manchester University Hospitals
Royal Manchester Children’s Hospital, UK

2. AIRWAY SURGERY
 EQUIPMENT
 TECHNIQUES
 TUBELESS AIRWAY
 ANAESTHESIA
 PROBLEMS
 ADVANTAGES
 DISADVANTAGES

3. Surgical procedures of the larynx and trachea in
infants and children present special problems
 Narrow anatomical field
 Aggravated by pathological changes
Shared airway
 Adequate oxygenation
 Cooperation

4. REQUIREMENTS FOR PAEDIATRIC AIRWAY
SURGERY
 Special equipment
 Sound knowledge of the airway
‐ Anatomy ‐ Physiology ‐ Pathology
 Tertiary referral centre (whenever possible)
 Excellent communication between anaesthetic
and surgical teams

5. ACCESS TO THE UPPER AIRWAY
 Rigid bronchoscopes
 Storz ventilating scope ± Hopkin’s rod
 Venturi scope (microtubes, jet ventilation)
 Fibreoptic scope
 Hopkin’s rod without bronchoscope

8. Suction
FGF
Prism
Light source
2.7 mm
Telescope Hopkin’s Rod
Light source

9. Suggested ETT and rigid bronchoscope
sizes
Age Cricoid Tracheal tube Bronchoscope size
diameter Size ID ED Size ID ED
Premature 4.0 2.5‐3.0 3.5‐4.0 2.5 3.2 4.0
Term 4.5‐5.0 3.0‐3.5 4.0‐4.9 3.0 4.2 5.0
6 months 5.0 3.5‐4.0 4.9‐5.4 3.0 4.2 5.0
1 yr 5.5 4.0‐4.5 5.4‐6.2 3.5 4.9 5.7
2 yr 6.0 4.5‐5.0 6.2‐6.9 3.5 4.9 5.7
3 yr 7.0 5.0‐5.5 6.9‐7.4 4.0 5.9 6.7
5 yr 8.0 5.5‐6.0 7.4‐7.9 5.0 7.0 7.8
10 yr 9.0 6.5 cuff
14 yr 11.0 6.5 cuff

10. METHODS FOR AIRWAY ANAESTHESIA
 Storz
 Spontaneous/IPPV
 Apnoeic oxygenation
 Jet ventilation (supraglottic and subglottic)
 Sanders Pneumothorax
 HFJV CO2 accumulation
 LFJV
 Tubeless field

11. ANATOMICAL DIFFERENCES
 Large tongue
 Long narrow epiglottis angled posteriorly
 Obligatory nasal breathers
 Soft high anterior larynx, easily displaced
 Narrowest part at the cricoid ring
 Short cricothyroid membrane
 Difficult cricothyroidotomy

12. Epig
Aryepiglottic
VC
Arytenoid
ETT Interarytenoid

13. AIRWAY PHYSIOLOGY
 Fixed tidal volume
 Minute ventilation depends on rate
 Diaphragmatic breathing
 Fewer type I muscle fibres
 Early fatigue
 FRC less than closing capacity
 Higher metabolic requirement
HYPOXIA

14. Infants less than 60 weeks postconceptual age are
at high risk of developing apnoea especially if
ex‐premature

15. PROCEDURES ON THE AIRWAY
 DIAGNOSTIC
 THERAPEUTIC

16. DIAGNOSTIC PROCEDURES
 Laryngomalacia (floppy or flipper larynx)
 Laryngo‐tracheo‐bronchomalacia
 Vocal cord dysfunction (palsies)
 Narrowing and stenotic lesions
 Glottic
 Subglottic
 Tracheal

17. DIAGNOSTIC PROCEDURES
 Tracheo‐oesophageal fistula
 Cysts (vocal cords)
 Clefts (larynx)
 Webs
 Tumours (papilloma)
 Inflammatory lesions

19. THERAPEURIC PROCEDURES
 Excision of lesions
 Laser
 Dividing Webs
 Removal of foreign bodies
 Stents for stenotic lesions (trachea)
 Correction of clefts (larynx)

20. ANAESTHESIA
 Pre‐anaesthetic assessment
 Anaesthetic room preparation
 Monitoring
 Induction
 Maintenance
 Analgesia
 Post‐anaesthesia care

21. PREANAESTHETIC ASSESSMENT
 Age at birth
 Post‐conceptual age
 Ventilatory problems at birth – IPPV
 Chronic lung disease and broncho‐pulmonary dysplasia
 Airway manifestations
 Previous anaesthetic charts
 Investigations
 Clear cervical spine (rigid bronchoscopes)
 Premedication

22. Airway manifestations
 Upper airway
 Obstruction
 Partial (monophasic or biphasic stridor)
 Complete (intubated – ICU)
 Oxygen saturation: low
 Lower airway: cough and wheeze
 Feeding: history of severe regurgitation

23. ANAESTHETIC ROOM
 Experienced assistant
 Local anaesthetic
 Spray
 Atomiser
 Airway equipment
Face masks LMAs
Tubes, stylets, bouggies Laryngoscopes
Suction Cricothyroidotomy - tracheotomy
 Laryngoscopes
 Straight blades
 Curved blades

24. MONITORING
 ECG
 BP
 SpO2
 ET CO2
 GAS

25. TUBELESS FIELD WITH HOPKIN’S ROD
 Unobstructed airway
 No endotracheal tube
 Nasopharyngeal airway for maintenance
 Telescope or Hopkin’s rod only

26. INDUCTION
 Securing IV access is preferable before
induction
 Inhalation induction
 Sevoflurane in O2
 Haluthane in O2
 Isoflurane?
 Desflurane?
 Maintain spontaneous breathing + CPAP
 Deep inhalation

27.  Confirm deep anaesthesia
 Centeral eye balls ‐ small pupils ‐ regular breathing
 Insert nasopharyngeal airway
 ETT of appropriate size stopping short of the airway
 Local anaesthesia to the airway
 Laryngoscopy
 Lignocaine 3mg/kg
 Spray
 LAD
 Assess the position of the tube
 Maintain spontaneous breathing through the
nasopharyngeal airway

28. Final picture: spontaneously breathing child with
anaesthetised airway and
no tube in the larynx
Tubeless Airway
Ready for procedure

29. ETT
Nasopharynx

30. MAINTENANCE
 Gas/O2
 Spontaneous breathing + CPAP (hand)
 Equipment
Tubes, stylets, bouggies LMAs
Laryngoscopes Ventilating bronchoscope
Suction Cricothyroidotomy - tracheotomy
 Drugs
 Adrenaline
▪Topical ▪ Nebulizer
 Dexamethasone
 Propofol

31. PROBLEMS
 Remember you are working on a degree of
obstruction to start with
 Too deep apnoea, loss of airway,
desaturation
 Light coughing, airway obstruction,
desaturation
 Inadequate CO2 monitoring

32. PROBLEMS
 Difficulty in maintaining spontaneous breathing
 Airway bleeding
‐ Obstruction ‐ Bronchospasm ‐ Desaturation
(Topical adrenaline and suction)
 Airway obstruction
‐ Bleeding ‐ Oedema
‐ Dislodgement of masses ‐ Trauma to the airway (rare)

33. ANALGESIA
 Local anaesthesia
 Paracetamol
 Ibuprofen

36. POSTANAESTHESIA
AIRWAY OEDEMA
AIRWAY BLEEDING

37. POSTANAESTHESIA
 Recovery position
 Adequate time in PACU
 Anaesthetic and surgical teams available

38. POSTANAESTHESIA
 Desaturation  Adrenaline nebulizer
 Stridor  1:1000 @ 0.5ml/kg
 Repeat PRN
 Obstruction
 Apnoea  Dexamethasone
 0.6mg/kg
 O2
 CEPAP
 Reintubate

40. ADVANTAGES
 Tubeless unobstructed field
 Less manipulation of the airway
‐ Intubation ‐ Extubation
 Facilitation of using larger instruments
 No muscle relaxants
 Little CO2 accumulation
 Minimal risk of pneumothorax

41. DISADVANTAGES
 No definitive airway
 Difficulty in monitoring breathing
 ET CO2
 Some CO2 accumulation

42. CONCLUSION
Tubeless airway field offers some advantages
for surgical procedures in a safe manner with
less complications

43. REFERENCES
 1. Albert SN. The Albert‐Sanders adaptor for ventilating anaesthetized patients for micro‐
laryngeal surgery. Br J Anaesth 1971; 43: 1098
 2. Baer G, Paloheimo M, Rahnasto J, et al. End‐tidal oxygen concentration and pulse oximetry for
monitoring oxygenation during intratracheal ventilation. J Clin Monit 1995; 11: 37
 3. Cowl CT, Prakash UB, Kruger BR. The role of anticholinergics in bronchoscopy: a randomised,
clinical trial. Chest 2000; 118: 188
 4. McRae K. Anesthesia for airway surgery. Anesthesiol Clin North America 2001;19: 497–541, vi
 5. Kain ZN, O’Connor EZ, Berde CB. Management of tracheobronchoscopy and esophagoscopy for
foreign bodies in children: A survey study. J Clin Anesth1994; 6: 28
 6. Ossoff RH. Laser safety in otolaryngology—head and neck surgery: anesthetic and educational
considerations for laryngeal surgery. Laryngoscope 1989; 99: 1–26
 7. English J, Norris A, Bedforth N. Continuing Education in Anaesthesia, Critical Care & Pain
Volume 6 Number 1 2006