الفهرس 
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Abstract
Successful management of the airway is the first priority when caring for sick, injured, or anesthetized children. The incidence of an unexpected difficult pediatric airway is low.
Recent advances in paediatric airway management contribute to a significant decrease in morbidity and mortality in paediatric anaesthesia. This thesis reviews the current concept of difficult paediatric airway with special emphasis on preoperative paediatric airway assessment. Newly introduced airway devices designed for paediatric patients may facilitate ventilation and intubation although their efficacy and safety profiles in difficult situations remain undetermined.
The present study attempts to shed light on some of the most important advances in paediatric airway management like, Air-Q ILMA assisted fiberoptic laryngoscopy, C-MAC video laryngoscopy, and Bonfils optical stylet for difficult airway management
The present study was approved by the local ethics committee of Alexandria Main University hospital and an informed written consent was obtained from guardianship of all participating paediatrics. The study was carried out on 60 children aged up to 5 years of both sexes with abnormal height to thyromental distance ratio (RHTMD) or COPUR scale ≥12 to predict difficult airway, these children with anticipated difficult airway were scheduled for elective surgical procedures under general anaesthesia with endotracheal intubation.
Preoperative airway assessment done clinically using RHTMD, and COPUR scale, laboratory using coagulation profile, and arterial blood gas analysis, and lastly radiological examination of the upper airway using lateral low kV plain X ray of the neck taken on inspiration with head in neutral position required for the following measurement:
i. Effective mandibular length (EML).
ii. Atlanto-occipital distance.
iii. Mandibulohyoid distance (MHD).
iv. Laryngeal Inlet.
v. The epiglottic angulation.
vi. Cricoid ring.
Preoperative preparation of all participating children was done using preoxygenation & topicalisation of airway with nebulized lidocaine to improve child’s acceptance of an airway device and block airway reflexes. It was used in conjunction with either inhalational or intravenous induction.
The anaesthetic plan individualised to the patient with a strong recommendation made to maintain spontaneous respiration initially and to intervene in a step-wise manner. If difficulty with a mask airway is anticipated, the method of induction of anaesthesia was considered carefully for instance in children with Apert’s syndrome breathing spontaneously on a facemask often leads to obstruction so it would be reasonable to proceed with intravenous induction using judicious doses of sedatives such as midazolam or fentanyl rather than inhalational induction. Conversely, children with Hunter or Hurler’s syndrome had a difficult mask airway & difficult intubation – a careful inhalational induction is the wisest course.
As regard intubation technique the included children were randomly classified into three groups using fiberoptic laryngoscopy 3.7mm through AirQ-ILMA in group I, Miller laryngoscope with Bonfils optical stylet in group II, and lastly styleted endotracheal tube with C-MAC video-laryngoscopy in group III.
The present thesis studied the changes as regard haemodynamic parameters, oxygenation, and ventilation of each child during and after intubation, and compared between three intubation techniques as regard the following;
i. Modified Cormack & Lehan’s score of each device.
ii. Number of intubation attempts.
iii. Need for assistance.
iv. Incidence of complications
v. Time of endotracheal tube insertion
vi. Time of successful attempt.
The results of the present study found correlation between different studied congenital syndromes and radiological findings. The current study demonstrated that mandibular hypoplasia syndromes such as Pierre Robin sequence, Treacher Collins, and Hemifacial microsomia )Goldenhar syndrome( had EML ≤ 5 cm, mandibulo-hyoid distance > 2.5 cm, and narrow laryngeal inlet < 2 cm.
While paediatrics with midfascial hypoplasia such as Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome had epiglottic angulation > 60° and atlanto-occiptal distance either < 2.5 cm or > 3.5 cm according to type of Craniosynostosis.
Furthermore paediatrics with mucopolysaccharidoses such as Hurler’s/Hunter’s syndrome, and Beckwith Wiedemann syndrome had laryngeal inlet < 2 cm, and epiglottic angulation > 60°.
The results of the present study demonstrated that the pressor response of intubation was significantly higher in group II & III relative to group I especially immediately after intubation and continued for 5 minutes after intubation, with bradycardia developed in group III immediately after intubation as a result of laryngeal stimulation.
The results demonstrated that hypoventilation occurred immediately after intubation in group I might be a result of longer intubation time, while regarding oxygenation there was no statistically significant difference between three groups.
As regard comparison between three intubation techniques the results of the present study demonstrated that intubation with flexible intubating fiberscope through Air Q ILMA was superior compared to other two devices regarding modified Cormack & Lehane’s score, and number of intubation attempts.
While intubation with Bonfils optical stylet or C-MAC videolaryngoscopy were superior compared to intubation with flexible fiberscope regarding need for airway specialized assistants or time of endotracheal tube insertion.
The results of the present study demonstrated no difference between three groups regarding complications.
from the present study we concluded that:
Paediatric airway may be complicated in a number of conditions; these conditions may result in difficulty in establishing or maintaining gas exchange.
Paediatric airway assessment is an important part of difficult airway management to predict type of difficulty.
Many techniques are available to manage paediatric airway difficulties.
Success of any of these techniques depends on constant maintenance of spontaneous ventilation and satisfactory depth of anaesthesia during the airway manipulation.
Radiological airway parameters were found to be strongly correlated with predicting difficulty in congenital syndromes compromising paediatric airway.
Intubation with flexible intubating fiberscope through Air Q ILMA was found to have a lesser intubation pressor response.
Intubation with flexible intubating fiberscope through Air Q ILMA was found to have superior modified Cormack & Lehane’s score compared to bonfils optical stylet and C-MAC videolaryngoscopy. Additionally it was found to have a lesser number of intubation attempts.
Conversely intubation with bonfils optical stylet or C-MAC video-laryngoscopy was found to be superior to flexible intubating fiberscope regarding need for airway specialized assistants or time of endotracheal tube insertion.
Radiologically predicted caudal larynx was found to be easily managed with staged technique of flexible intubating fiberscope.