Management of the Unexpected Difficult Airway in Neonatal Resuscitation

Abstract

A "difficult airway situation" arises whenever face mask ventilation, laryngoscopy, endotracheal intubation, or use of supraglottic device fail to secure ventilation. As bradycardia and cardiac arrest in the neonate are usually of respiratory origin, neonatal airway management remains a critical factor. Despite this, a well-defined in-house approach to the neonatal difficult airway is often lacking. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Infant (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the delivery room (DR) and neonatal intensive care unit (NICU). Experience from anesthesiology is that a "difficult airway algorithm," advance planning and routine practicing, prepares the resuscitation team to respond adequately to the technical and non-technical stress of a difficult airway situation. We learned from observing current approaches to advanced airway management in DR resuscitations in a university hospital and make recommendations on how the neonatal difficult airway may be managed through technical and non-technical approaches. Our recommendations mainly pertain to DR resuscitations but may be transferred to the NICU environment.

Keywords: algorithm; difficult airway; endotracheal intubation; newborn; resuscitation.

Figure 1

The modified Cook's practical classification of laryngeal view. “The view is easy (E) when the laryngeal inlet is visible. These views are suitable for intubation under direct vision. The view is restricted (R) when the posterior glottic structures (posterior commissure or arytenoid cartilages) are visible or the epiglottis is visible and can be lifted. These views are likely to benefit from indirect methods (e.g., gum elastic bougie). A difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. These views are likely to need advanced methods for intubation.” The figure and text are reproduced from “A new practical classification of laryngeal view; Anesthesia, 2000, 55, 260–287” with permission from Prof. T. M. Cook, MD, 21.01.2021, and RightsLink/John Wiley and Sons. The photographic part (with the blue background) minus photo “Grade 3b” (Grade 3b: Reprinted with permission from openairway.org.) along with other minor changes by author G. Berisha, MD, has been reproduced with permission from Carin A. Hagberg, MD, FASA, 08.10.2021.

Figure 2

Proposed algorithm for the management of the neonatal unanticipated difficult airway. The red column describes the situation where mask ventilation is difficult and/or impossible to achieve despite measures including the insertion of an oropharyngeal or nasopharyngeal tube, and two-person mask ventilation. The red column is the most time critical. The blue column is the situation where mask ventilation is possible, but the newborn is difficult to intubate, e.g., a semi-vigorous baby where positive pressure ventilation is considered ineffective or prolonged. In this situation there is usually time to reevaluate the initial management plan and reposition the head of the newborn for another intubation attempt with a videolaryngoscope. DR, Delivery Room; FONA, Front of neck access; NICU, Neonatal intensive care unit; SAD, Supraglottic airway device.