Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
Conflicts of Interest
 None
Scary Airways:
What Have We
Learned?
Dawn M. Sweeney, M.D.
Associate Professor of
Anesthesiology and Pediatrics
University of Rochester Medical
Center
Goals and Objectives
What is a Scary Airway?
 recognize
 Any
What is the purpose of a Scary
Airway?
Anecdote 1
 To
 The
that the signs and symptoms of
airway foreign bodies may be subtle
 discuss the incidence of airway
anatomical issues in children with
congenital heart disease
 describe instances when a different
intraoperative approach might be
needed
keep us from getting complacent
keep us searching for new and better
ways to care for children with scary
airways
 To keep us motivated to maintain and
better our skills for managing difficult
airways.
 To
airway that makes you stop and think
about what you did, and about what you
did not do!
 It is not necessarily only an airway for
which things did not go well.
 It is possible (and often preferable)to be
scared of an airway even if everything
goes well.
case of the persistent mother
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
Anecdote 1
What Do You Want to Do?
You are on call, and currently finishing a
supracondylar fracture. There are 2 or 3 more
supracondylar fractures in the ED.
 The ENT resident approaches you to tell you
that there is a 9 month old in the ED with a
possible airway foreign body, but that the
possibility is low. The baby looks fine, and the
ENT team thinks it will be fine to wait until after
the fracture cases are finished. The choking
event occurred on Thursday, and it is now
Monday evening.
 Will
Examine the Baby
What Next?
The baby is brought to preop holding to be
seen when we finish the current fracture.
 She is quiet, breathing quietly without
apparent increased work of breathing
 Her oxygen saturations are in the mid to high
90’s in room air
 Mother says she sounds hoarse when
vocalizing, and that the pediatrician had
seen the baby earlier in the day and said she
had croup.
 While


you wait until the fractures are done?
you call in another team?
 Do you have another plan in mind?
 Do you want more information?
 Do you trust the ENT resident’s assessment
of the situation?
 Will
you are speaking to the mother, the
baby suddenly flops forward, bangs her
head on the wooden arm of the chair,
then sits back up, shakes her head a little,
and continues to sit placidly in her
mother’s arms.
 What do you think about this?
And Again!
A
couple of minutes later, the flopping
occurs again. The baby is again not
distressed by hitting her head on the
wooden chair arm.
 What is going on?
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
What Did We Find?
What Did We Learn?
 The
corner of a McDonald’s ketchup
packet lodged just below and between
her vocal cords.
 There was significant granulation tissue in
this area resulting in a 2 mm airway.
 The
Anecdote 2
I have an Interesting Case
 It’s
 It
always at 5:00 PM on a Friday!
signs of an airway foreign body can
be very subtle, even in the presence of
significant airway obstruction.
 The ENT team was pretty convinced that
we would find only signs of croup and no
FB.
 If her mother had listened to the
pediatrician, this child might have died at
home.
is 5:00 PM on a Friday, and a colleague
calls you and asks if you are still at the
hospital.
 He has an interesting airway case, and
would like you come and look at the
baby.
Anecdote 2
Physical Exam
 The
 There
patient is a 49 day old male infant
with progressive enlargement of his
tongue since birth.
 He has no respiratory symptoms, but has
been losing weight due to poor feeding.
is a tense sublingual mass that has
displaced the tongue up towards the
hard palate.
 A CT scan shows a 2.4 cm by 2 cm cystic
mass arising from the base of the tongue.
 The baby is thin, but is not in any
respiratory distress.
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
What Did We Do?
 There
was plenty of room posteriorly in the
mouth, so we placed an LMA after letting
him suck on some viscous lidocaine and
induced anesthesia through the LMA.
 The mass was marsupialized.
 The baby had no problems during
emergence or recovery.
 He was discharged to home the next day.
What Did We Learn?
Anecdote 3
 Sometimes
 You
it is not as bad as it looks!
look at the schedule and discover
that you are scheduled for a
craniosynostosis repair the following day.
 You then find out the child has AntleyBixler Syndrome.
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
Antley-Bixler Syndrome
 Difficult
to see in photo, but the head has
a very short A-P distance, and is shaped
somewhat like an M& M.
 These children can have multiple
craniofacial abnormalities including
choanal atresia or stenosis.
 They can be extremely difficult to intubate
to mask ventilate and intubate.
Anecdote 3
 You
read further in the chart and discover
that the child has a tracheostomy.
Preoperative Evaluation
What Next?
 You
 You
speak with the parents who state that
there is nothing new going on with the
baby. He has no new respiratory
problems or increase in secretions.
 His physical exam reveals slightly coarse
breath sounds, but good air entry with no
wheezing or rales present.
take the baby to the OR, induce
anesthesia with the baby breathing
spontaneously through his uncuffed Shiley
tracheostomy.
 You spend the 90 minutes obtaining
venous and arterial access (these patients
also have radial and foot anomalies).
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
What About the Airway?
Really?
 You
decide to replace the tracheostomy
with a cuffed endotracheal tube for the
procedure as there is considerable
leaking around the tracheostomy.
 You give a dose of pancuronium, remove
the tracheostomy, place the ETT, inflate
the cuff, and you are immediately unable
to ventilate this child.
 You
Now What?
Case Cancelled
Somehow the baby actually has ROSC. Not
clear how we managed that in the face of
limited oxygenation and ventilation.
 The ENT surgeon arrives and prepares to
perform bronchoscopy.
 Bronchoscopy reveals bilateral mainstem
bronchi granulomas and demonstrates ballvalve effect with positive pressure ventilation.

try multiple maneuvers, including
replacing the tracheostomy, replacing
the ETT, calling for an ENT surgeon,
worrying about a false passage,
continuing to try to ventilate and
oxygenate.
 The baby has a cardiac arrest, PALS is
initiated.
The ENT surgeon removes the granulomas,
and the craniosynostosis repair is cancelled.
 The baby recovers from the anesthesia
without event, and is sent to the PICU for
observation overnight.
 In speaking with the parents postoperatively,
they share with you that they had replaced
the tracheostomy multiple times over the
weekend due to suspicion that it was
plugged, but that it had not been found to
be plugged. (It would have been nice to be
told about this preoperatively.)

What Did We Learn?
Anecdote 4
 That
 You
sometimes things are much more
difficult than they look.
 Sometimes parents don’t mention
important issues. (for a variety of reasons)
are scheduled to anesthetize a 4
month old with “pink” Tetralogy of Fallot.
 She has developed tachypnea which is
being attributed to possible pulmonary
over circulation and congestive heart
failure.
 She is tachypneic with feeding in
particular, but is otherwise doing well.
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
Off to the OR
You bring the baby to the OR, perform an
inhalation induction without incident, and a
peripheral IV is placed.
 You give a dose of pancuronium, and
prepare to intubate.
 Your resident is unable to pass a 3.5 ETT.
 You are then also unable to pass a 3.5 ETT, a
3.0 ETT, or a 2.5 ETT.
 In each case, you are able to pass the ETT a
few millimeters below the vocal cords, but no
further.

What Now?
You call the pediatric ENT surgeon (yes, there
is only one)who is at his clinic (a couple of
miles from the hospital).
 You describe the situation, and tell him you
think it might be complete tracheal rings.
 He says that maybe it is only subglottic
stenosis, cancels his clinic patients, and
comes over to perform bronchoscopy and a
cricoid split.

What Did We Find?
What Did We Learn?
 Complete
 It
tracheal rings
woke the patient up without an ETT,
took her to the PICU to recover overnight,
and then discharged her in the morning.
 She subsequently went to another
institution for slide tracheoplasty and
incidental TOF repair.
is not always the heart!
 We
Tracheal Defects and
Congenital Heart Defects Can
Occur Together
How Can We Diagnose This
Before Going to the OR?
 Both
 It
patients I have seen with complete
rings had TOF
 Up to 11% of patients with TOF may have
a tracheal abnormality
 Should babies with TOF be screened for
tracheal anomalies?
Starc M, Berdon WE, Starc TJ. Undiagnosed primary tracheal stenosis in tetralogy of Fallot:
complete tracheal rings with a low carina. Pediatr Radiol. 2014 Mar; 44(3):362-3.
is currently unclear if we should be
screening babies with congenital heart
defects for complete tracheal rings.
 For pulmonary artery sling, this should
really be considered.
 Should babies with Tetralogy of Fallot be
screened since 11% may have tracheal
rings?
Sweeney, Dawn, MD
Scary Airways: What Have We Learned?
Heart Defects and tracheal
Stenosis
Other Cardiac Anomalies
Associated with Tracheal
Stenosis
 30%
 60%
of tracheal stenosis is associated with
pulmonary artery sling (I have never seen
this)
 The left pulmonary artery arises from the
right pulmonary artery
 This can either compress a normal
trachea or be associated with tracheal
rings
Thank you!
of babies with complete tracheal
rings have congenital heart defects.
 AV Canal, VSD, TOF, TAPVR, and ASD
have all been seen with complete
tracheal rings.
 20% of babies with complete tracheal
rings have Trisomy 21.