1. Upper airway obstruction in pediatric
patients from anesthesiologist vew
Prof. Mirjana Shosholcheva
University clinic of surgery “St. Naum Ohridski”
Medical faculty-Skopje, Macedonia
One of the most challenging clinical situations mandating nursing skills is assessment, rapid diagnosis and management of the acute airway obstruction in children. Although many airway disorders exist, obstruction of the upper airway is the most potentially life-threatening situation.
The main goal is to prevent cardiac arrest or irreversible brain damage that occurs within minutes of complete airway obstruction.
Good outcome can be ensured by appropriate management with implementation of preventive aspects of airway obstruction and training in basic life support techniques, as this situation requires an immediate, aggressive response.

2. Disclosures
No financial disclosures
No conflict of interest

3. Key points Causes of airway obstruction in children
Signs of airway obstruction
Airway obstruction with foreign body
Airway obstruction during emergence from anaesthesia
Management of laryngospasm
Securing the airway in a child with airway obstruction

4. Epidemiology and mortality
Upper airway obstruction accounts for up to 15% pediatric emergency*
The major causes are:
Viral croup (80%)**
Epiglotitis (5%)
Foreign body aspiration
Failure to manage the airway is the leading cause of preventable pediatric deaths
Infants and children decompensate more quickly compared to adults
Narrowing of the upper respiratory tract has an exponential effect on airflow because linear airflow is a function of the fourth power of the radius (Hagen-Poisell equitation). Although UAO occurs at any level of the upper respiratory tract, laryngeal obstruction has a particular importance because larynx is the narrowest portion of the upper airway. The narrowest portion of the larynx is at the glottis in adults and the subglottis in infants
* Loftis L. Emergent evaluation of acute upper airway obstruction in children.
Reprint from Up to date
** Manno M. Pediatric respiratory emergencies: Upper airway obstruction and infections. In: Marx J, ed.
Rosen's Emergency Medicine: Concepts and Clinical Practice . 7th ed. Philadelphia, Pa: Mosby Elsevier;
2009:chap 166

5. Important causes of airway obstruction in children
Life-threatening emergency
Laryngospasm after tracheal
extubation –major of UAO after surgery
Depressed
conscious level
Congenital
anomalies
Post-extubation laryngospasm
Anaphylactoid
reactions
Rapidly
progressive
Airway
obstruction
Infections
Many of the infectious causes of upper airway obstruction have lost their threat today as a result of the progress made in preventing and treating these infections.
Infections: Viral tracheobronchitis (croup); infectious mononucleosis
| Bacterial: epiglottitis, tracheitis, tonsillitis, retropharyngeal, peritonsilar abscess
Foreign bodies: airway foreign body, esophageal foreign body
Trauma: blunt and penetrating injury
Congenital anomalies: choanal atresia, micrognathia, macroglossia, hereditary angioedema
Acute upper airway obstruction from any cause can be a life-threatening emergency in the pediatric patient and unless promptly diagnosed and appropriately managed, complete obstruction will result in respiratory failure followed by cardiac arrest in a matter of minutes.
Thermal injury
Airway
foreign body
Trauma
*Morton NS. Large airway obstruction in children: causes, assessment
and management. Update Anaesthesia 2004; 18 (article 13):1

6. Signs of airway obstruction in children
conscious patient
unconscious or
sedated patient
marked respiratory distress
altered voice
dysphagia
the hand-to-the-throat choking sign
stridor, facial swelling
prominence of neck veins
absence of air entry into the chest
tachycardia
inability to ventilate with
a bag-valve mask
asphyxia progresses to cyanosis
bradycardia
hypotension
irreversible cardiovascular collapse
A quick evaluation considering age group, history, physical examination, and clinical circumstances helps determine the site and cause of obstruction, the severity of the obstruction, and the need to establish an airway urgently
Stridor is heard during the entire respiratory cycle but typically intensifies during inspiration and is usually more prominent above the neck. The presence of stridor indicates severe airway obstruction, (airway passage <5 mm) but unfortunately does not help to specify its nature or location.
Obstructive noise or stridor is specific for UAO

7. Specifics regarding signs of airway obstruction in children
Mild upper airway obstruction
child recovering from anaesthesia
tonsillar hypertrophy and obstructive sleep apnea
Signs of partial upper airway obstruction include biphasic snoring and mild desaturation
Severe, non-complete, progressive airway obstruction
increased work of breathing
respiratory failure
Hypoxemia
cardiac arrest
Children with severe croup, tracheitis, epiglottitis, airway burns
Trauma, depending on its severity and location, may produce immediate or progressive obstruction

8. Signs of increased work of breathing
Tachypnea
Paradoxical respiration “See-saw” pattern of breathing
(dyssynchrony between rib cage and abdomen)
Suprasternal, intercostal, and subcostal retraction along with an increased use of accessory muscles of respiration
auto CPAP
Position: Infants may assume an opisthotonic position; the "tripod" or sniffing position is seen in the older child

9. Stridor Inspiratory stridor Expiratory stridor
airway compromise at
the supraglotic or laryngeal level
Stridor: inspiratory stridor indicates airway compromise at the supraglotic or laryngeal level, while expiratory stridor is indicative of intrathoracic obstruction. It is very important to be noticed that the magnitude or severity of stridor does not correlate with the severity of obstruction
intrathoracic obstruction
The magnitude or severity of stridor does not correlate with the severity of obstruction

10. Signs of ineffective breathing and respiratory failure:
Cyanosis
Altered consciousness
Bradypnea, apneic spelss
Silent chest in spite of vigorous effort
Post-extubation laryngospasm,
angiooedema and
anaphylactoid reactions
Compleet airway obstruction
Compleet airway obstruction is signaled by gagging, choking. absent breath sounds and aphonia in the case of large foreign bodu aspiration. this rapidly progresses to cyanosis, bardycardia and cardiac arrest.
Complete airway obstruction in the abscense of foreign body aspiration is seen in post-extubation laryngospasm, angiooedema and anaphylactoid reactions
Choking, absent breath sounds and aphonia
This rapidly progresses to cyanosis, bardycardia and cardiac arrest

11. Airway obstruction with foreign body
Foreign-body aspiration is a relatively frequent accident and
a leading cause of accidental death in children under 5 years of age
Diagnosis of foreign body aspiration should be suspected in children who do not respond to appropriate intervention
Laryngeal impaction is life-threatening
(large or sharperdged foreign bodies may lodge in the larynx)
Most foreign bodies pass the vocal
cords and lodge in the lower airways (bronchi -80%)
Symptoms can mimic other diseases such as croup or asthma

12. Airway obstruction with foreign body
Nasal foreign bodies
unilateral rhinorrhea and stinking breath
Oropharyngeal foreign bodies :
mouth breathing
Children with a history of choking and subsequent symptoms must be referred to immediate bronchoscopy!
A diagnosis of foreign-body aspiration should also be considered whenever a child exhibits unexplained symptoms that are refractory to medical treatment and are consistent with airway obstruction
What about the child who has stridor and wheezing?
The causes of stridor and wheezing in older infants and children include
foreign bodies in the airway and in the esophagus
and combination of infectious causes

13. Management of airway obstruction with foreign body
*if the child can cough and verbalized it is placed in
the position of comfort and oxygen is given
IV line placement and other interventions which may agitate
the child in this case are avoided
X-ray evaluation for localization can be performed
urgently in stable children
The presence of asphyxia indicates the need
for immediate resuscitation and securing the airway
*Schmidt H., Manegold BC. Foreign body aspiration in children. Surg Endosc 2000; 14:644-8

14. 1. Mild oedema of the respiratory mucosa
“Circulus viciosus”
BLS maneuvers
(Heimlich, Guidel )
Most patients can
be discharged
within 24 h
direct laryngoscopy
Magill forceps
or suction
Complications
1. Mild oedema of the respiratory mucosa
2. Tracheobronchitis
3. granulation tissue
flexible
bronchoscopy
When BLS maneuvers are not successful, direct laryngoscopy should be performed. In some cases the foreign body may be removed with a Magill forceps or suction when it is above the vocal cords. Extraction with rigid bronchoscopy is usually performed in the most cases for suspected or confirmed obstruction with foreign body. Prior evaluation by flexible bronchoscopy might be justified in unclear cases but provisions should be made to provide immediate rigid bronchoscopic management. Complications after successful foreign-body removal are rare. Inflammatory responses, such as mild oedema of the respiratory mucosa, tracheobronchitis or granulation tissue resolve without sequelae. Routine use of steroids or antibiotics is not indicated. Most patients can be discharged within 24 h. Repeat bronchoscopy may be indicated if there is uncertainty about complete removal. A short course of corticosteroids may be helpful before repeat bronchoscopy in cases where mucosal swelling does not allow complete visualisation of the lower airways. Potential complications, such as bronchial stenosis, bronchiectasis, abscess formation or perforation are more likely to occur the longer the foreign body remains in the airways.
short course of corticosteroids
Repeat
bronchoscopy
rigid bronchoscopy

15. The foreign body is withdrawn by a forceps through the bronchoscope
Child is in respiratory distress!
inhalational induction with 100% oxygen and sevoflurane
After loosing the consciousness. i.v. cannula
TIVA with propofol and fentanyl
gentle assistance with inhalational technique
cords are sprayed with local anaesthetic
rigid bronchoscope with a ventilating side arm is inserted,
facilitated by laryngoscopy
When the child is in respiratory distress, inhalational induction with 100% oxygen and sevoflurane is given. After loosing the consciousness. i.v. cannula is introduced. TIVA using propofol and fentanyl is administrated: the child may become apneic after induction if the work of breathing was severely increased. Children may require gentle assistance even with inhalational technique. The cord are sprayed with local anaesthetic and a rigid bronchoscope with a ventilating side arm is inserted, facilitated by laryngoscopy. Desaturation may occur as “the clean” lung is excluded from ventilation and higher FiO2 may be required. High ventilating pressures are not recommended, as the foreign body, if partially mobile, might be displaced into a distal airway and than retrieval might be more difficult. Dexamethadone is administrated to reduce edema and stridor. The foreign body is withdrawn by a forceps through the bronchoscope. Laryngeal edema might be worsen after multiple insertions of the rigid bronchoscope, and post-procedure reintubation might be required.
higher FiO2
The foreign body is withdrawn by a forceps through the bronchoscope
Dexamethadone
Laryngeal edema might be worsening after multiple insertions of the rigid bronchoscope, and post-procedure reintubation might be required

16. Securing the airway in a child with airway obstruction – General considerations
Laryngoscopy and intubation
volatile anaesthetics
Sevoflurane might be choice, but its use has some controversy,
because lower potency of sevoflurane may not permit intubation
The Jackson-Rees modification of Ayer,s “T piece” circuit
- CPAP
For the intubation, volatile anaesthetics are used. Sevoflurane might be choice, but its use has some controversy, because lower potency of sevoflurane may not permit intubation.
In many centers halothan in 100 oxygen is still very frequent choice. The concentration is increased by 0.5% every 10 breaths, gradually increasing the concentration up to 5%.
Attempts to assist ventilation against complete obstruction
are usually futile!
Alveolar ventilation in these children is severely compromised. Uptake of volatile
agents is very slow and induction of anaesthesia may take more than 15 min

17. Any attempt at “asynchronous” assistance leads to complete obstruction, especially in large foreign bodies
“Synchronized” assistance (analogous to triggered ventilation)
is very helpful to maintain oxygenation

18. intubation is difficult or impossible
As the depth of anaesthesia increases, the child may be gradually lowered to the supine position
flexible fiberoptic
bronchoscopy
intubation is difficult or impossible
If the condition of the child deteriorates, cricothyrotomy and ventilation through a T piece circuit can be considered
Jet ventilation is not appropriate as it may lead to barotrauma

19. The safest option is emergent tracheostomy under musk anaesthesia for most children who cannot be intubated in one or two attempts

20. Controversy associated with heliox therapy in UAO
Heliox has been used in several conditions: postextubation laryngeal edema, tracheal stenosis or extrinsic compression, status asthmaticus and angioedema
To be effective, the helium–oxygen ratio must be at least 70:30
Although the work of breathing and dyspnea improves to some degree with the use of heliox, the mechanical obstruction is still in place
The use of heliox in patients with severe UAO should only be used to provide temporary support pending definitive diagnosis and management

21. Algorithm for management of upper airway obstruction

22. Infective causes of airway obstruction
acute clinical syndrome of hoarse voice, barking cough and stridor
Today many of the Infective causes of airway obstruction have lost their threat as a result of the progress made in preventing and treating these infections. Prompt recognition and appropriate management of the child presenting with upper airway obstruction due to the infective causes remains critical, because certain causes can progress rapidly from a mild to a potentially lifethreatening disease state
Radiological presentation of subglottic oedema in viral croup (left) compared with a normal trachea (right)
Endoscopic view of subglottic oedema
in viral croup
There is some controversy regarding treatment with epinephrine
Usually affects children from 6 months to 4 years of age, with a peak incidence at 2 years of age

23. Epiglotitis Controversy! To look or not to look
Epiglottitis is a serious, life-threatening infection and an airway emergency. It is characterised by acute inflammatory oedema and hyperaemia involving the supraglottic structures, above the epiglottis itself and the aryepiglottic folds.
Supraglottitis is a more appropriate description
Also, controversy exists regarding management of the epiglottitis although the incidence of this disease has decreased dramatically. To look or not to look, visualization of the epiglottitis in a child with acute stridor and in whom the diagnosis of epiglottitis is not usually advocated. However the presence of anesthesiologist provides reliable approach in this case.
Schematic (left) and endoscopic view (right) of epiglottitis.
Lateral neck radiographs of a normal child (left)
and a child with epiglottitis with the typical thumb sign (right).
Conversely, epinephrine is not effective in the treatment of epiglottitis
and may be deleterious.
Controversy! To look or not to look

24. Airway burns
Heat produces an immediate injury to the airway mucosa  edema
Suspect for inhalation injury
Exposure in an enclosed space
Decreased level of consciousness, confusion
Soot in mouth, nares
Carbonaceous sputum
Airway burns often progress rapidly to acute upper airway obstruction, but still allow time for the child to be intubated under anaesthesia.
Swelling, ulceration of oral mucosa or tongue
Dyspnoea
Increased work of breathing
Hoarseness
Oxygen saturations <94% in air
Caboxyhaemoglobin >5% on co-oximetry
Stridor, wheeze, crepitations

25. Effect of deep face burns on airway maintenance are:
Airway obstruction by intraoral and laryngeal edema
Anatomic distortion by face and neck edema, which increases
the difficulty of endotracheal intubation
Oral edema decreasing clearance of intraoral secretion
Impaired protection of the airway from aspiration
Maintaining an adequate airway!
There is insufficient data to support a treatment standard or a treatment guideline for the diagnosis of inhalation injury.
However, maintaining an adequate airway is essential for successful early management. There are four standard criteria (the four P’s) for the need for endotracheal intubation
A judgment decision must be made in the initial assessment as to whether the airway can be managed safely without an endotracheal tube. When in doubt, it is safer to intubate, as airway burns often progress rapidly to acute upper airway obstruction, but still allow time for the child to be intubated under anaesthesia
Maintain airway patency
Protect against aspiration
Pulmonary toilet to decrease mucous plugging and infection risks
Need for positive-pressure
When in doubt, it is safer to intubate!

26. Endotracheal tube complications
TRAUMATIC LESIONS
Damage from endotracheal intubation and
tracheotomy
Even the dictum that ‘cuffed endotracheal tubes should not be used in
children under the age of 8 years’ can no longer be maintained
since the development of high-volume, low-pressure cuffs*
Endotracheal tube complications
incorrect size, traumatic or multiple intubations
up and down movements of the endotracheal tube
inadequate analgesia and sedation, whereby the infants struggle while intubated
Complications and damage of the upper airway may occur during the endotracheal intubation as so as when longterm endotracheal intubation was introduced for pediatrics requiring prolonged ventilator support. Acquired subglottic stenosis is problem that can be resolved with experience of choosing appropriately sized tubes thus preventing tube trauma and particular care of the intubated patient
*Newth CJL, Rachman B, Patel N, Hammer J. The use of cuffed versus
uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004; in press

27. Cuff vs Uncuffed Endotracheal Tube
Controversial issue
Traditionally, uncuffed ETT recommended in children < 8 yrs old to avoid post-extubation stridor and subglottic stenosis
Arguments against cuffed ETT: smaller size increases airway resistance, increase work of breathing, poorly designed for pediatric patients, need to keep cuff pressure < 25 cm H2O
Arguments against uncuffed ETT: more tube changes for long-term intubation, leak of anesthetic agent into environment, require more fresh gas flow > 2L/min, higher risk for aspiration -

28. Concluding Recommendations-
For “short” cases when ETT size >4.0, choice of cuff vs uncuffed probably does not matter
Cuffed ETT preferable in cases of:
high risk of aspiration (ie. Bowel obstruction),
low lung compliance (ie. ARDS, pneumoperitoneum, CO2 insufflation of the thorax, CABG),
precise control of ventilation and pCO2 (ie. increased intracranial pressure, single ventricle physiology)
Golden, S. “Cuffed vs. Uncuffed Endotracheal tubes in children: A review” Society for Pediatric Anesthesia. Winter 2005 edition.

29. Laryngeal Mask Airway – WHEN?
Supraglottic airway device
Flexible bronchoscopy, radiotherapy, radiologic procedures, urologic, orthopedic, ENT and ophthalmologic cases are most common pediatric indications for LMA
Useful in difficult airway situations, and as a conduit of drug administration (ie. Surfactant)
Different types of LMAs: Classic LMA, Flexible LMA, ProSeal LMA, Intubating LMA
Disadvantages: Laryngospasm, aspiration

30. Concern:light plane of anesthesia!
Airway obstruction during emergence from anaesthesia
Postoperative laryngospasm - life-threatening complication
aspiration, airway obstruction
Tracheal extubation
awake
deep anesthesia
Concern:light plane of anesthesia!
Tracheal extubation can be performed while pediatric patients are awake or under deep anesthesia. Both techniques have their pros and cons.
A small number of studies involving children show a greater incidence of upper airway complications with awake extubation as a result of increased airway reactivity. However, the endpoint for wakefulness in these studies was taken as swallowing; the incidence of respiratory complications dramatically decreased when extubation was performed when eyes were open, with spontaneous ventilation. Extubation under deep anaesthesia decreases cardiovascular stimulation and reduces the incidence of coughing and straining on the tube.
Laryngospasm is most frequently caused by local irritation by blood or saliva and is likely to occur during light planes of anaesthesia, when the children are neither able to prevent this reflex nor generate an adequate cough. The incidence can be reduced if they are left undisturbed in the lateral recovery position until they wake up.
local irritation by blood or saliva
light planes of anaesthesia
Child undisturbed - in the lateral recovery position
Hypoventilation
Hypoxemia
Hypercarbia
Cardiac dysrhythmias
Cardiac arrest

31. Emergence and extubation: A systemic approach
Can this patient be extubated while deeply anesthetized?
Yes No
No rezidual NMB
Easy musk ventilation
Easily intubated
Not at increased risk for
regurgitation/aspiration
- Normothermic
Difficult musk ventilation
Difficult intubation
Residual NMB present
Full stomach
Can this patient be extubated immediately following
surgery and emergence from general anesthesia?

32. Can this patient be extubated immediately following
surgery and emergence from general anesthesia?
Yes No
Awake
Following commands
Breathing spontaneuosly
Wheel oxigenated
Not excessively hyperbaric
(PaCo2  50 mmHg
Fully recovered from MR
Sustained head lift
Strong hand grip
Strong tongue protrusion
- Hypoxic (O2 saturation < 90 mmHg)
- Excessively hyperbaric(Pa CO2 >50mm Hg
- Hypothermic (< 34 C)
- NMB present

33. complete laryngospasm
Partial laryngospasm
complete laryngospasm
inspiratory stridor
absence of air movement
Tracheal tug and paradoxical (“see-saw”) movement of the abdomen
Increased airway problems
children with a history of a recent upper respiratory tract infection
former premature infants
children with chronic, obstructive sleep apnea
Anesthesiologists should anticipate increased airway problems in three groups of children:

34. Managament of laryngospasm
jaw thrust maneuver, neck extension and mouth opening
mild biphasic snoring-noisy breathing
placing the child in the “safe” position
The presence of secretions in the oropharynx may be responsible for these complications. However, data have not shown that extubating the trachea when the patient is fully awake leads to decreased hypoxemia compared to tracheal extubation while deeply anesthetized
oxygen by face mask
positive pressure with a bag and face mask may be required
along with a naso-pharyngeal airway
If necessary a dose of succinylcholine followed by tracheal re-intubation (in children older than 2 years!!!)

35.  Of particular concern have been the instances of life-threatening malignant hyperpyrexia and reports of rare, but often fatal, hyperkalaemic cardiac arrests in young boys with undiagnosed muscular dystrophy. As a result of these reports, in 1994, the US Food and Drug Administration (FDA) recommended that ‘the use of succinylcholine in children should be reserved for emergency intubation and instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for i.m. use when a suitable vein is inaccessible’. Since the publication of this recommendation, the use of succinylcholine in routine anaesthesia in children has been declined.

36. RISK OF CARDIAC ARREST FROM HYPERKALEMIC RHABDOMYOLYSIS
This syndrome often presents as peaked T-waves and sudden cardiac arrest
within minutes after the administration of the drug in healthy appearing
children (usually, but not exclusively, males, and most frequently 8 years
of age or younger).
There have also been reports in adolescents.

37. Recent concerns about the elective use of succinylcholine in pediatric patients have focused on the occasional reports of hyperkalemic cardiac arrest, particularly in children with undiagnosed Duchenne muscular dystrophy. The incidence of Duchenne muscular dystrophy is only 1 in 3000 to 8000 male children. The revised labeling continues to permit the use of succinylcholine for emergency control of the airway and treatment of laryngospasm. Succinylcholine is the only neuromuscular blocking agent currently available that has been demonstrated to be effective after intramuscular (IM) administration when emergency control of the airway is required and there is no IV access. In this circumstance, the dosage must be increased to 4 to 5 mg/kg IM. Atropine is administered simultaneously. Following IM succinylcholine, onset of neuromuscular blockade takes approximately 2 to 5 minutes; the response in patients who are hypotensive or hypovolemic is unpredictable. 

38. In the Proposed Approach to the management of
laryngospasm first of all is to think of:
Airway irritation/obstruction
Blood/secretions
Light anaesthesia
Regurgitation

39. The main aim is to rapidly oxygenate child!
100% oxygen (warm, humidified,
oxygen enriched air mixture in neonates)
Visualize and clear pharynx/airway
Jaw thrust with bilateral digital pressure behind
temporomandibular joint, oral/nasal airway
Deepen anaesthesia with propofol (20% induction dose)
Succinylcholine 0.5 mg/kg to relieve laryngospasm
( mg/kg i.v. or 4.0 mg/kg i.m. for intubation
Be aware of use in children < 2 years old!!!
Intubate and ventilate

40. Airway obstruction in the postoperative period
post-intubation croup
Laryngeal edema - in neonates and infants = inspiratory
stridor within 6 h of extubation (Subglottic edema of 1 mm in neonates
can reduce the laryngeal lumen by 35%)
- Supraglottic oedema
- Retroarytenoidal oedema
- Subglottic oedema
Associated risk factors
The incidence seems to be decreasing as anesthesiologists have started to use smaller tracheal tubes and ensuring there is an air leak below cms water pressure
However there are no enough evidences that cuffed tracheal tubes that have been used in small children increased incidence of croup. Perhaps the wider use of steroids during adeno-tonsillectomies, one of the pediatric operations with greater risk, may be a factor in the decrease in postintubation croup
tight fitting tube
trauma at intubation
duration of intubation >1 h
coughing on the tube
change of head and neck position during surgery

41. Management of laryngeal edema
warm, humidified, oxygen enriched air mixture
nebulized epinephrine 1:1000 (0.5 ml kg−1 up to 5 ml)
dexamethasone 0.25 mg kg−1 followed
by 0.1 mg kg−1 six hourly for 24 h
reintubation with a smaller tube in severe cases

42. Conclusion
● Upper airway obstruction (UAO) is a life-threatening emergency that requires prompt diagnosis and treatment
● Severe UAO can be surprisingly asymptomatic at rest if it develops gradually. Sudden clinical deterioration is unpredictable
● Patients with possible UAO must never be sedated until the airway is secured. Minimal sedation may precipitate acute respiratory failure
● Achievement of airway patency in total airway obstruction and reestablishment of ventillatory airflow is the first and foremost goal of the anaesthesiologists

43. Conclusion
● Critical care physicians must be aware that pharmacologic interventions (epinephrine, steroids, and heliox) provide temporary support but cannot significantly improve mechanical UAO
● Bronchoscopy constitutes the most accurate diagnostic tool and frequently provides the best way to correct UAO
● Cricothyroidotomy is the surgical intervention of choice to reestablish airflow when medical interventions have failed

44. Conclusion
If the anaesthesiologist is competent in the full range of airway access procedures and when appropriately management is performed, the possibility of incidence and consequences of acute airway obstruction in children will be very low

45. Thank you