influenced by the patient's anatomy.
Flexible fiberoptic bronchoscopy is usually considered the gold
standard for managing difficult tracheal intubation in both adults and
children, and pediatric anesthesiologists have become better at
manipulating the ultrathin scope. But bronchoscopy is still more chal-
lenging in children, for several reasons, including the unique anatomi-
cal variance of infants and children. Ultrathin bronchoscopes,
required for smaller patients, can't be manufactured with effective
suction ports, so secretions and blood are more likely to obscure the
view. It's important to use an antisialagogue (glycopyrrolate, for exam-
ple) and to briefly and gently suction the oropharynx before the pro-
cedure.
Apneic oxygenation is usually ineffective in small children because they
desaturate faster and require alternate means of oxygenation during intuba-
tion. And flexible bronchoscopy performed through a supraglottic airway
(SGA) is more difficult because SGAs are more likely to be wrongly posi-
tioned in children, which leads to an obscured view of the glottic opening.
Many types of video laryngoscopes are designed for pediatric patients.
Comfort and familiarity are the keys. I'm most familiar with a laryngoscope
that has an angled camera at its end. It provides a better view of the vocal
cords and the glottis than you can get with your own eyes.
Unanticipated difficult ventilation
When difficulties arise with ventilation, a sequential series of correc-
tive maneuvers can usually eliminate any obstruction. First, reposi-
tion the head and neck while simultaneously checking for appropri-
ate facemask placement. Chin lift, which stretches and tightens the
soft tissue structures along the length of the upper airway, may alle-
viate the obstruction. If that fails, jaw thrust (with fingers under the
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