Airway Management in Patients With Abnormal Anatomy or Challengin

Abstract:
Most pediatric intubations that occur

in the emergency department are in
patients without identifiable risk fac-
tors for difficulty. Infants and children
go through a predictable pattern of
Airway
development that impacts airway
management. A careful, stepwise
approach to the identification of the
Management in
Patients With
truly difficult pediatric airway is criti-
cal to avoid morbidity and mortality.
Difficulty can be encountered in
Abnormal
cases of challenging anatomy such as
congenital airway or midface ab-
normalities or with acquired condi-
Anatomy or
tions such as croup or epiglottitis.
Physiologically, intrinsic lung disease
(ie, asthma) and shock states have
Challenging
unique features that impact airway
management.
Keywords:
intubation; pediatric; anatomy;
physiology; difficult airway Physiology
Nathan W. Mick, MD, FACEP
S
uccessful airway management in the emergency depart-
ment (ED) requires a stepwise, rigorous approach in
order to identify and mitigate risk factors for difficulty.
These risk factors, including such things as trauma,
obesity, and malignancy, are relatively more common in the adult
population than in children. Airway management in children is
predictably different, both anatomically and physiologically, than
Tufts University School of Medicine, Boston,
in the adult population, but not inherently difficult in most cases.
MA; Department of Emergency Medicine,
These anatomic and physiologic differences are most pronounced
Maine Medical Center, Portland, ME.
Reprint requests and correspondence:
in the first 2 years of age, during which most of the normal
Nathan W. Mick, MD, FACEP, Department of developmental changes in airway structures occur.
Emergency Medicine, Maine Medical Difficulty in pediatric airway management can occur in the rare
Center, 22 Bramhall St, Portland, Maine case of anatomic disruption from either infection or trauma,
04102. congenital malformations that affect the airway structures, or
mickn@mmc.org more commonly when dealing with the physiologic stresses
resulting from acute illness. Careful attention to maximizing
1522-8401 preintubation conditions and developing a structured approach to
© 2015 Elsevier Inc. All rights reserved. the identification of the potentially difficult airway maximizes the
likelihood of successful intubation.
186 VOL. 16, NO. 3 • AIRWAY MANAGEMENT IN PATIENTS WITH ABNORMAL ANATOMY OR CHALL... / MICK
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en julio 13, 2021. Para uso personal
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AIRWAY MANAGEMENT IN PATIENTS WITH ABNORMAL ANATOMY OR CHALL... / MICK • VOL. 16, NO. 3 187
NORMAL ANATOMIC AND PHYSIOLOGIC cricoid ring. Historically, the pediatric trachea has
been described as “conical” rather than cylindrical
DEVELOPMENT which has led to the common practice of placing
uncuffed endotracheal tubes during intubation.
Anatomic Considerations More recent literature examining airway anatomy
There are several distinct anatomic and physio- in anesthetized pediatric patients by bronchoscopy
logic differences that impact airway management in or magnetic resonance imaging suggests that the
the young infant and child. These differences are airway may be less conical than previously believed,
most distinct in the first 2 years of life, while with the subglottic region actually shaped like an
children aged 2 to 8 years are transitioning to more ellipse. 1–3 Thus, although uncuffed tubes are per-
adult-like anatomy and physiology. Anatomically, fectly acceptable, cuffed endotracheal tubes are
infants have a relatively large occiput in relation to considered equally safe to use based on randomized
their body size. This impacts optimal positioning for trials and current Pediatric Advanced Life Support
airway management as an infant lying prone on a recommendations, in cases where high airway
stretcher will actually be in slight flexion at the neck pressures (ie, asthma, acute respiratory distress
owing to the size of the occiput. This can make it syndrome, multifocal pneumonia) or changing
challenging to optimally align the oral, pharyngeal, compliance is anticipated, or when aspiration is a
and laryngeal axes for direct laryngoscopy. A line risk. 4,5 Pediatric cuffed endotracheal tubes are now
drawn horizontally through the external auditory made with the ability to carefully manage cuff
canal should pass just anterior to the shoulder and pressure with a cuff manometer or by auscultating
be parallel to the bed in a patient who is positioned for air leak which lessens the likelihood of cuff
correctly for intubation (Figure 1). A towel roll overinflation and damage to the subglottic struc-
placed under the shoulders of a small infant can be tures. The pediatric trachea is also more prone to
used to overcome the large occiput and should be dynamic collapse during periods of agitation or
used for optimal positioning. Older infants and partial airway obstruction (ie, croup). The flexibility
children (age, 6 months to 5 years) most often of the upper airway can result in “complete”
need no support, whereas adolescents and adults collapse without complete obstruction. Positive
may require head support to achieve appropriate pressure, such as that provided by bag-valve-mask
positioning prior to intubation. (BVM) ventilation can stent open a partially
Small children also have relatively large tongues in obstructed upper airway and should be considered
relation to their oral cavity and a large floppy epiglottis the initial rescue technique of choice in these cases.
which can impact visualization of airway structures Although exceedingly rare in clinical practice,
during direct laryngoscopy. The large tongue predis- pediatric airway management at times calls for the
poses the child to obstruction when sedated or placement of a surgical airway. The cricothyroid
obtunded, although this can be mitigated by the use membrane in children younger than 10 years is
of an appropriately sized oral or nasal airway. exceedingly small and open surgical cricothyroidot-
Similarly, direct manipulation of the epiglottis using omy is not recommended as a rescue technique. In
a straight (Miller) blade is often required to achieve these small children, needle cricothyroidotomy
visualization of the vocal cords. Children also have should be considered as an alternative. This tech-
larger, more vascular tonsillar and adenoidal tissue nique has been studied in animal models and allows
which is prone to bleeding with manipulation during for oxygenation for a defined period (a minimum of
airway procedures and can lead to partial airway 30 minutes based on dog models), during which
obstruction with decreased levels of consciousness. definitive airway control can be attained. 6,7
The vocal cords are at the level of the first cervical
vertebrae in infants and drop to the C3-4 level by age
7 years before attaining their adult position near C6 Physiologic Considerations
by late adolescence. This normal developmental Infants and small children have a high metabolic
pattern impacts endotracheal intubation as the rate and lower functional residual capacity when
airway structures in infants and younger children compared with adults. Thus, desaturation can
will appear “higher and more anterior” than those in occur in a much more precipitous and rapid fashion
an older adolescent or adult, although again this can even with appropriate preoxygenation during air-
be mitigated by meticulous attention to preproce- way management. A fully preoxygenated adult
dure positioning. patient with healthy lungs will not desaturate
Anatomically, the narrowest fixed portion of the below 90% with apnea for as long as 6 minutes. A
pediatric airway is subglottic at the level of the normal, healthy 10-kg child who is fully
Figure 1. Use of head or shoulder roll by age. Optimal airway alignment occurs when a line drawn through the external auditory canal
passes just anterior to the shoulder and is parallel to the bed. In an infant, achieving this relationship requires a roll placed under the
shoulders. In a small child, no support is typically needed. In an adolescent, a roll placed under the head achieves the correct positioning.
Used with permission from Airway Management Education Center.
preoxygenated will desaturate in roughly half that Mask seal—the inability to achieve a tight mask
time. A child who is hypoventilating or has intrinsic seal can make BVM difficult such as that which
lung disease will often experience an extremely occurs with facial hair, secretions, blood or
rapid fall in oxygen saturation with apnea. Children vomitus, or in cases of micrognathia.
also have a large extracellular fluid volume which Obstruction/obesity—upper airway obstruction
requires increased doses of certain medications (such as from infection or foreign body) can
used in rapid sequence intubation (RSI; ie, succi- impede BVM as can obesity.
nylcholine) to achieve effect. Age—advanced age (N 55 years) is a marker of
difficult BVM and does not apply to pediatric
patients.
No teeth—teeth provide the “strut” against
IDENTIFICATION OF THE DIFFICULT which the mask sits to achieve adequate seal. If
PEDIATRIC AIRWAY BVM proves difficult in the small child without
Difficulty with airway management in children teeth, consider the use of an oral airway.
may arise from difficulty with BVM ventilation, Stiff lungs—increased airway resistance can
endotracheal intubation, or difficulty applying res- impede effective BVM and can occur in cases of
cue techniques. This can range from difficulty obstructive lung disease (asthma) or infection
achieving a mask seal during BVM to the exceed- (multifocal pneumonia).
ingly rare “can't intubate, can't ventilate” scenario. As BVM is often the first and most appropriate
Analysis of the National Emergency Airway Registry airway rescue technique used during endotracheal
(NEAR III) found that 3% of more than 17 500 ED intubation, a careful assessment of difficulty is
airways (primarily adult patients) were ultimately advisable prior to intubation attempts. Difficulty
managed with a technique other than the one with direct laryngoscopy can be predicted by
initially chosen, but only 0.1% of these required following the LEMON mnemonic:
surgical cricothyrotomy. 8 The incidence of a truly
difficult intubation in pediatric airway management Look externally—the gestalt assessment of the
in the ED setting is estimated to be much less than airway is sensitive but not specific for difficult
1% of cases. A diligent, structured preprocedure intubation. The general appearance of the airway
airway assessment is necessary to identify factors (presence of trauma, obvious signs of obstruction
which may portend difficulty. Although not formally such as airway swelling from anaphylaxis, or
studied in children, Walls and Murphy 9 have put syndromic facial features) should be assessed.
forward characteristics that predict difficulty in Evaluate 3-3-2 (Figure 2)—in order for direct
airway management in adults, many of which might laryngoscopy to be successful, there must be
also be applied to children. The absence of literature adequate space to display oral tissues to create a
does not negate the benefits of a meticulous direct line of sight. Utilizing the width of the
preprocedure assessment in children. patient's own fingers, the 3-3-2 rule assesses for
Difficulty with BVM can be encountered when mouth opening (the first “3”), the distance
any of the following characteristics are present between the mentum and hyoid bone (the second
(mnemonic MOANS): “3”), and the distance between the superior
Figure 2. The 3-3-2 rule for the assessment of airway difficulty. Using the width of the patient's own fingers, the 3-3-2 rule assesses for
mouth opening (A), the distance between the mentum and hyoid bone (B), and the distance between the superior notch of the thyroid
cartilage and neck/mandible junction (C). Used with permission from Airway Management Education Center.
TABLE 1. Applying the LEMON assessment in children.

Look • Gestalt is the most important predictor of airway difficulty in children.
• Presence of dysmorphic features are associated with abnormal airway anatomy and may predict difficulty.
• Small mouth, large tongue, recessed chin, and major facial trauma are usually immediately apparent.
Evaluate • May be difficult to perform in an uncooperative child, or infants with characteristically redundant neck tissue.
(3:3:2) • If 3:3:2 assessment is performed, use the child's fingers, not the provider's.
Mallimpati • Cooperation may be an issue.
• Limited data in children.
Obstruction/ • Second to the gestalt Look, assessing for obstruction is perhaps the most fruitful step and common means of identifying
obesity difficulty airways in children.
• A focused, disease-specific history and physical examination (voice change, drooling, stridor, retractions) can accurately
identify children with acute or chronic upper airway obstruction.
• Obesity is an increasing concern, though the impact on pediatric airway management is likely to be less significant than in
adults.
Neck • Limited positioning in immobilized pediatric trauma patients is similar to adults.
• Intrinsic cervical spine immobility from congenital abnormalities and acquired conditions (e.g. ankylosing spondylitis and
cervical rheumatoid arthritis) are very rare in young children.
Data from Nagler J. Luten R. The difficult pediatric airway. In Walls RM, Murphy MF eds. Manual of Emergency Airway
Management, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2012).
notch of the thyroid cartilage and neck/mandible Surgery—prior surgery in the neck (ie, prior
junction (the “2”). tracheostomy for congenital airway anomalies)
Mallampati score—it assesses the amount of can be an impediment.
mouth opening and ability to see past the tongue Mass—the presence of a neck mass such as a
and is only reliably assessed in the awake, hematoma is a marker of the potential for difficult
cooperative patient. surgical techniques.
Access—if access to the neck structures is
Obstruction/obesity—similar to BVM, the pres-
difficult, then surgical techniques may be as well.
ence of upper airway obstruction or morbid
obesity can make direct laryngoscopy difficult. Radiation—prior radiation therapy can alter
tissue planes in the neck (not a common concern
Neck mobility—correct positioning for direct in pediatrics).
laryngoscopy requires the clinician to be able to
Tumor—intrinsic airway tumors (ie, cancer or
place the patient in the “sniffing” position and
such things as hemangiomas) can make surgical
flex at the neck (in small infants by placing a
airway techniques difficult.
towel roll under the shoulders, in older adoles-
cents by elevating the head) and extend at the When difficulty with direct laryngoscopy is
head. This is not possible in some scenarios such predicted based on the LEMON mnemonic, the
as the trauma patient in a cervical collar where clinician should consider calling for additional
neck movement is not advisable. resources and personnel if time allows. In some
cases, the patient's clinical status is such that
The LEMON criteria for predicting difficult airway waiting for help is not feasible. Consider the case
have been recently validated using a large airway of a child with anaphylaxis to peanuts who presents
registry. 10 Many of the difficult laryngoscopy pre- with rapidly progressing airway edema. Although
dictors are due to acquired conditions that become the assessment of difficulty would be “positive,” the
more common as a patient ages. A child who child's condition may be such that delaying may be
“passes” the gestalt look externally is unlikely to detrimental. These “forced to act” scenarios may
harbor difficult laryngoscopy features. Application necessitate actions that would not be considered if
of the key feature of the LEMON criteria for children there were more time. Rapid sequence intubation in
is summarized in Table 1. these scenarios is not contraindicated as they afford
Difficulty with needle or open surgical airway the clinician the opportunity for a best, first attempt
techniques can be assessed by following the SMART and if unsuccessful, then consideration of rescue
mnemonic: techniques may be necessary.
Figure 3. Radiograph of epiglottitis. Lateral soft-tissue neck radiograph of a young adult with epiglottis. Note the “thumb-print sign” of a
swollen epiglottis (arrow). Used with permission from Nathan Mick, MD.
ANATOMICAL DIFFICULTY Abnormal neck mobility. Both Down syndrome and

the mucopolysaccharidoses are associated with
Congenital Airway Anomalies cervical spine instability and care must be taken
Various congenital anomalies can impact airway during positioning for and performance of
management. Although rare, these conditions laryngoscopy.
should be considered in a child who appears Large tongue. Macroglossia is associated with
syndromic. The various anatomic abnormalities Down syndrome and Beckwith-Wiedeman syn-
and their impact on airway management are drome as well as the mucopolysaccharidoses, and
summarized below: a large tongue may obstruct the airway during
BVM and prevent adequate visualization during
Abnormal head size or shape. Macrocephaly due to direct laryngoscopy.
hydrocephalus or a misshapen head (ie, Crouzon Airway masses. Airway hemangiomas or cystic
syndrome) can affect airway management by hygromas can obscure visualization of the glottic
making it difficult to optimally position the child structures and, in some cases, are prone to bleeding
for direct laryngoscopy. with manipulation during tube placement.
Micrognathia. Micrognathic conditions (ie, Pierre-
Robin sequence or Treacher Collins syndrome) are
characterized by mandibular hypoplasia which UPPER AIRWAY OBSTRUCTION
make direct laryngoscopy difficult due to the lack Upper airway obstruction in children can be due
of “compressible space.” To adequately move oral to infection (ie, croup or epiglottis) or foreign body.
tissues out of the way in order to visualize the glottic Airway management in these scenarios requires a
structures, the tongue and oral structures must be thorough understanding of the epidemiology and
compressed into the mandible and elevated. With a pathophysiology of these disease processes to avoid
small jaw, the usable space is diminished and morbidity and mortality.
visualization may be compromised. In these condi-
tions, neuromuscular blockade and RSI should be
used with extreme caution. In cases where it is not Epiglottitis
feasible to defer intubation to the operating room Epiglottitis results from bacterial infection of the
under controlled conditions, ketamine (dose 1-2 supraglottic structures and can lead to upper airway
mg/kg) and a sedated look may be prudent. obstruction (Figure 3). The incidence of this disease
Videolaryngoscopy (Verathon Medical Inc., Bothell, in children has declined with the advent of the
WA Karl Storz, Tuttlingen, Germany) may be useful recommended vaccination for Haemophilus influenza
as this technology obviates the need to align the type B, although sporadic cases still occur in
oral, pharyngeal, and laryngeal axes and can unvaccinated or incompletely vaccinated children
essentially be used to “see” around the corner and or due to other bacteria. Typically, a patient with
visualize the glottic structures. Extraglottic devices epiglottitis will present with the relatively abrupt
such as a laryngeal mask airway or King tube may be onset of high fever, drooling, and stridor and will
useful as rescue devices. appear clinically toxic. Such a patient would be
identified as a difficult airway by failing both the as this are successful, then the child can be
“gestalt” look (L in the LEMON mnemonic) as well recovered, observed in the ED, and potentially
having evidence of obstruction (the O in the LEMON discharged. If the Heimlich is unsuccessful, then
mnemonic). The ideal setting for airway manage- direct laryngoscopy/videolaryngoscopy with Magill
ment in this clinical scenario is in the operating forceps and attempts at removal should be
room with both anesthesia (to perform a controlled attempted. A significant proportion of childhood
mask induction with inhalational anesthetics) and a choking episodes result with the foreign body at the
surgeon skilled in surgical airway management level of the vocal cords, acting as a “ball-valve”
present. In the ED, allowing the patient to assume obstruction. These foreign bodies may be amenable
a position of comfort which will maximize air to removal. If a patient appears to be completely
exchange while not agitating the child is critical. obstructed, and during direct laryngoscopy no
Agitation in cases of partial airway obstruction can foreign body is visualized, then the obstruction is
worsen symptoms and precipitate respiratory ar- likely below the level of the vocal cords. In this
rest. If the child clinically deteriorates in the ED (ie, scenario, using a styletted endotracheal tube to
the “forced to act” scenario), BVM should be the push the foreign body distal into one of the
first technique used as this may serve to stent open mainstem bronchi (typically the right as the take-off
the incompletely obstructed airway and allow for angle is shallower) and then withdrawing the
oxygenation and ventilation. Direct laryngoscopy or endotracheal tube to the predicted appropriate
videolaryngoscopy can be attempted as most pa- insertion depth and ventilating the unobstructed
tients with epiglottitis can be intubated orotrache- lung should be the next maneuver. In cases where a
ally. The airway aperture is diminished by swelling suspected foreign body is not visualized during
so having endotracheal tubes several sizes smaller direct laryngoscopy, the obstructing object must be
than predicted and using a stylet is advisable. If below the level of the glottis or subglottis. Therefore,
orotracheal intubation is not possible due to the needle or surgical cricothyroidotomy will not bypass
degree of swelling, a supraglottic airway such as a the obstruction and will offer no advantage.
laryngeal mask airway is unlikely to be helpful due to
the difficulty in achieving a seal over the glottis and
the higher than normal airway pressures anticipat-
Physiologic Difficulty
In the ED, intubation difficulty due to physiologic
ed. Failed orotracheal intubation necessitates the
derangement in children is a much more common
performance of a surgical/needle cricothyroidotomy
clinical scenario than the relatively rare congenital
(can't intubate, can't ventilate scenario) which can
anomaly or upper airway obstruction. Disrupted
be lifesaving in a patient with epiglottitis with normal
physiology adds, a layer of complexity to what in
lower airway anatomy and lung function.
many instances is already a high-risk, high-stress
situation. Optimizing pulmonary and hemodynamic
parameters is essential to avoid morbidity during
Foreign Body Aspiration
endotracheal intubation.
Foreign body aspiration is a relatively common
cause of upper airway obstruction in children
accounting for more than 17 000 ED visits and Status Asthmaticus
more than 100 deaths every year. 11 Children aged 1 Asthma is characterized by obstruction due to
to 3 years are at highest risk due to a less bronchospasm and inflammation of the small
coordinated swallowing mechanism and their ten- airways. Most asthma can be aggressively treated
dency to put things in their mouths. Although many medically with a combination of inhaled broncho-
cases of foreign body aspiration are not clinically dilators, corticosteroids, and adjuvant medication
obvious, this diagnosis should be suspected in the such as magnesium sulfate. Although it is relatively
afebrile, nontoxic child with stridor who does not rare for asthma to progress to respiratory failure,
have preceding upper respiratory infection symp- status asthmaticus represents a high-risk condition
toms or congestion suggestive of croup. The initial with regard to airway management.
management of suspected foreign body aspiration in The decision to intubate an asthmatic patient is
the partially obstructed child is identical to that of fraught with difficulty. At the ends of the clinical
epiglottitis, namely, keeping the child calm and spectrum, the decision can be more clear-cut. The
arranging for definitive management in the operat- child that is tachypneic but awake and alert with
ing room. If the child deteriorates and progresses to normal or near normal oxygen saturations likely
complete obstruction, the first maneuver should be does not require intubation, and it is unlikely that
the Heimlich. If basic life support maneuvers such mechanical ventilation would provide additional
benefit above what they are providing for them- Delayed sequence intubation (DSI) has been
selves. On the other end of the spectrum is the child suggested as an alternative technique to RSI in
who is altered and hypoventilatory with dropping cases of hypoxic respiratory failure in adults.
saturations or rising pCO2. In the middle of these 2 Proponents of DSI suggest giving ketamine in order
extremes is a large population of children where to facilitate preoxygenation in the hypoxic, agitated
aggressive medical treatment and close observation patient followed by neuromuscular blocking agents
will be required. Once the decision to intubate has in a delayed fashion. The literature supporting DSI is
been made, it is critical to optimize physiology as limited to case series and there is no evidence in
much as possible to mitigate the respiratory and children and, as such, is not recommended at
hemodynamic changes that accompany mechanical this time. 12
ventilation. Most children will benefit from a fluid
bolus (20 mL/kg of normal saline or lactated
ringers) to counteract the drop in systemic venous Shock
return due to increased intrathoracic pressure Shock, from sepsis, pump failure, blood loss, or
that occurs with positive pressure ventilation. anaphylaxis, presents unique challenges during
Preoxygenation can be difficult due to the under- airway management because of the hemodynamic
lying obstructive lung pathology, and apnea time changes that occur with the procedure. Children
before desaturation can be incredibly brief (on the respond to hypovolemia with an increase in heart
order of seconds). Bag-valve-mask ventilation is rate. Hypotension is a late and often premorbid
often difficult due to airway obstruction and finding in shock states in pediatrics. The child in
higher than normal airway pressures should be shock who requires endotracheal intubation
anticipated. should be aggressively volume resuscitated with
Unless difficult airway predictors are present, RSI crystalloid (or blood in cases of acute blood loss
should be considered the airway management anemia). The provision of potent sedatives during
technique of choice in the ED. Ketamine adminis- induction and the increased intrathoracic pres-
tration causes release of endogenous catechol- sures that occur with positive pressure ventilation
amines and therefore has inherent bronchodilatory can both impede venous return and precipitate or
properties. Therefore, it is a useful induction agent exacerbate hypotension. Both etomidate and
followed by either succinylcholine or rocuronium to ketamine are “hemodynamically-neutral” induc-
induce paralysis. Direct laryngoscopy ideally is tion agents. There has been controversy regarding
performed quickly by an experienced laryngoscopist the use of etomidate in the setting of adrenal
in order to minimize apnea time to avoid progressive insufficiency in septic shock states. 13–15 Etomi-
hypoxemia or hypercarbia. A cuffed endotracheal date causes a drop in circulating cortisol, but
tube should be strongly considered if available. there are no well-designed prospective trials that
Ventilator settings after intubation should be set to show worse outcomes in those patients with sepsis
minimize the likelihood of barotrauma. A low tidal or septic shock who receive the drug. Therefore,
volume (ie, 6-8 mL/kg) is used initially with careful this should not be considered an absolute contra-
attention to peak (b 40 cm H2O) and plateau indication for etomidate use.
pressures (30-35 cm H2O) to avoid barotrauma.
Inspiratory time is normal or decreased, and the
ventilatory rate is lower to allow for complete
exhalation (ie, I:E ratios of 1:4 or longer). Allowing SUMMARY
for complete exhalation avoids breath-stacking and Airway management in the pediatric population
“auto-peep.” These ventilator strategies, although is a rare but critical skill necessary for emergency
necessary, are physiologically “uncomfortable” and physicians. Although technically straightforward,
aggressive postintubation sedation is often required there are numerous normal anatomic and phys-
to prevent ventilator dysynchrony. Ketamine, either iologic differences between adult and pediatric
by intermittent bolus or infusion, or benzodiaze- patients that must be understood. True anatomic
pines are reasonable choices for postintubation difficulty, particularly secondary to congenital
sedation. When opioids are required, some rec- airway abnormalities, is rare. Physiologic abnor-
ommendations favor the use of synthetics (eg, malities including those found in cases of ob-
fentanyl) over nonsynthetics (eg, morphine) to structive lung disease and shock states can be
decrease the risk of histamine release and resul- mitigated by aggressive preprocedure resuscita-
tant bronchospasm, although limited comparative tion and a careful, thoughtful approach to airway
data exist. management.
9. Walls RM, Murphy MF. Identification of the difficult and failed

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Abstract:

Most pediatric intubations that occur

TABLE 1. Applying the LEMON assessment in children.

ANATOMICAL DIFFICULTY Abnormal neck mobility. Both Down syndrome and

9. Walls RM, Murphy MF. Identification of the difficult and failed

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