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Complications of pediatric airway management for anesthesia
Authors: Narasimhan Jagannathan, MD, MBA, Nicholas Burjek, MD
Section Editors: Carin A Hagberg, MD, Lena S Sun, MD
Deputy Editor: Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2018. | This topic last updated: Mar 14, 2018.
INTRODUCTION — Perioperative complications of airway management are more common in children than
adults, and may result in critical events, including cardiac arrest.
The incidence, prevention, and management of airway­related complications in children during anesthesia will
be reviewed here. Basic principles of airway management for pediatric anesthesia are discussed separately.
(See "Airway management for pediatric anesthesia".)
INCIDENCE OF AIRWAY RELATED COMPLICATIONS — Airway and respiratory events are the most
common perioperative complications in pediatric patients [1­3]. Several studies have reported on the
incidence of pediatric airway­related complications. Consistently reported risk factors for serious airway
complications include very young age and multiple intubation attempts.
The Pediatric Perioperative Cardiac Arrest Registry found that respiratory events lead to 27 percent of all
pediatric perioperative cardiac arrests. Laryngospasm was the most common cause of respiratory­related
arrests; other etiologies included airway obstruction, difficult intubation, esophageal intubation, and
aspiration [4].
A prospective observational multicenter cohort study of severe critical events in anesthesia (the
Anaesthesia PRactice In Children Observational Trial [APRICOT] study) included 31,127 anesthetics in
pediatric patients across 33 European countries [2]. Respiratory and airway events accounted for 60
percent of all anesthesia­related complications and occurred in 3.1 percent of all anesthetics;
laryngospasm occurred in 1.2 percent, bronchospasm in 1.2 percent, postoperative stridor in 0.7 percent,
and aspiration in 0.1 percent of all anesthetics. The highest rates of airway and respiratory events
occurred in neonates (<1 month old) and infants (<1 year old). Other risk factors for respiratory
complications included history of prematurity and reactive airway disease.
A multicenter registry study of difficult intubations in 13 children's hospitals in the United States (the
Pediatric Difficult Intubation [PeDI] study) found that among 1018 cases of difficult intubations, 20 percent
had at least one complication [5]. The most common severe complication was cardiac arrest (2 percent of
patients), and the most common nonsevere temporary complication was hypoxemia (oxygen saturation
[SpO2] <85 percent). Risk factors for complications included weight <10 kg, more than two intubation
attempts, short thyromental distance, and three or more attempts at direct laryngoscopy before switching
to a more advanced intubation technique.
The effect of the choice of airway device on the incidence of perioperative respiratory adverse events
(laryngospasm, bronchospasm, and postoperative stridor) is discussed separately. (See "Airway management
for pediatric anesthesia", section on 'Supraglottic airway versus endotracheal tube'.)
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HYPOXEMIA — Infants and young children are particularly prone to rapid oxygen desaturation, hypoxemia,
and
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Infants have high vagal tone compared with adults, and are likely to experience severe bradycardia and
cardiac arrest in response to hypoxemia, particularly when combined with stimulation of the airway. Among
1018 children who were difficult to intubate, hypoxemia (>10 percent decrease from preintubation oxygen
saturation [SpO2] for more than 45 seconds) occurred in 9 percent of patients, and cardiac arrest occurred in
16 percent of these patients who became hypoxemic [5]. All cardiac arrests were preceded by hypoxemia.
Strategies for avoiding hypoxemia during airway management in children are discussed separately. (See
"Airway management for pediatric anesthesia", section on 'Maintenance of oxygenation'.)
LARYNGOSPASM — Laryngospasm can occur during induction, maintenance, or emergence from
anesthesia, and most commonly occurs during light levels of anesthesia. Laryngospasm must be recognized
and treated rapidly to prevent complications. In most cases, laryngospasm responds to treatment without
sequelae, but oxygen desaturation, bradycardia, negative pressure pulmonary edema, aspiration, and cardiac
arrest can occur.
Laryngospasm is the reflex closure of the false and true vocal cords, accompanied by the descent of the
epiglottis over the laryngeal orifice. Laryngospasm may progress from inspiratory stridor, retractions, and
rocking chest wall movement with inspiration, to complete cessation of air movement despite inspiratory
effort.
Risk factors for laryngospasm — The incidence of laryngospasm during anesthesia is higher in children
than in adults, and ranges from 1.7 to 25 percent [6­8]. Factors that increase the risk of laryngospasm during
anesthesia include the following:
Airway instrumentation during light anesthesia.
Vocal cord irritation by inhalation anesthetics, secretions, mucus, or blood.
Young age, with infants at highest risk [6].
Recent or current upper respiratory infection [9,10].
Passive smoke exposure [11].
Obstructive sleep apnea.
Airway anomaly.
Airway procedures (eg, tonsillectomy) [12].
Prevention of laryngospasm — Strategies that may be used to prevent laryngospasm during induction of
anesthesia include the following:
Delay elective surgery for children with current or recent upper respiratory infection. (See "Anesthesia for
the child with a recent upper respiratory infection", section on 'Timing of elective procedures'.)
Suction nasal and oropharyngeal secretions, if present.
Perform laryngoscopy, intubation, or insertion of a supraglottic airway (SGA) during deep plane of
anesthesia (ie, sevoflurane with or without propofol).
For children over the age of one year, use an SGA rather than an endotracheal tube (ETT) when either
would be appropriate. (See "Airway management for pediatric anesthesia", section on 'Supraglottic
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airway versus endotracheal tube'.)
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Administer muscle relaxant for intubation.
Continue or find out more.
Management of laryngospasm — Treatment for laryngospasm should commence as soon as it is
recognized. Steps for management are described here and appear in an algorithm (algorithm 1) [13].
Administer 100 percent oxygen by facemask.
Obtain tight mask seal, and deliver continuous positive airway pressure with jaw thrust, neck extension,
and mouth open. If necessary, place oral airway, particularly if the nasal airway is obstructed (eg, by
nasal secretions, adenoids, anatomic factors).
Deepen anesthesia with sevoflurane or propofol.
If no improvement, administer medications as follows:
• Succinylcholine 0.25 to 0.5 mg/kg intravenous (IV), if bradycardia occurs, atropine 0.02 mg/kg IV;
OR succinylcholine 3 to 4 mg/kg IM, if bradycardia occurs, atropine 0.02 mg/kg IM.
• Ventilate by mask, SGA, or endotracheal intubation until neuromuscular block resolves.
BRONCHOSPASM — Bronchospasm can occur during anesthesia as a result of stimulation from an airway
device, aspiration of gastric contents, anaphylaxis, or underlying reactive airway disease. Prevention and
treatment of bronchospasm during anesthesia are discussed separately. (See "Anesthesia for the child with
asthma or recurrent wheezing", section on 'Intraoperative bronchospasm'.)
ASPIRATION — Aspiration of gastric contents is a rare complication of pediatric airway management, with
reported incidences ranging from 0.02 to 0.1 percent of all anesthetics in children. Patients are instructed to
fast preoperatively to empty the stomach and reduce the risk of aspiration and the severity of pulmonary
effects if aspiration occurs. (See "Preoperative fasting guidelines", section on 'Pediatric patients' and
"Preoperative fasting in children and infants".)
Risk factors for aspiration — Risk factors for aspiration in children include American Society of
Anesthesiologists (ASA) physical status of III or IV and emergency procedures [2,14­16]. While most studies
find the highest rates of aspiration at induction and laryngoscopy, up to one­half of these events may occur
during maintenance of anesthesia or at extubation [2,14]. Light anesthesia and high intra­abdominal pressure
(eg, due to lithotomy positioning) are additional risk factors for aspiration during maintenance with a
supraglottic airway (SGA) in place [14].
Aspiration events during maintenance of anesthesia are more common in patients managed with an SGA,
mask anesthetic, or natural airway rather than an endotracheal tube (ETT). (See "Airway management for
pediatric anesthesia", section on 'Supraglottic airway versus endotracheal tube'.)
Management of aspiration — If an aspiration event is suspected, the patient should be placed in head down
position. Immediate management should include the following steps:
Remove an SGA, if used, as it can trap gastric contents at the glottic opening.
Suction the mouth and pharynx, and administer 100 percent oxygen by face mask.
Evaluate for laryngospasm and bronchospasm, and treat as necessary. (See 'Laryngospasm' above and
'Bronchospasm' above.)
For large particle aspiration, summon assistance to evaluate for possible rigid bronchoscopy.
Subsequent management depends on the severity of signs and symptoms, the timing of the aspiration, the
perceived cause of aspiration, and the urgency of the procedure.
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Outcome and disposition after aspiration — Morbidity from pulmonary aspiration varies widely, ranging
from
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in pediatric patients, pulmonary sequelae
occur in one­third to three­fifths of patients who aspirate [14,16]. If pulmonary sequelae occur, they do so
within two hours of aspiration. Therefore, patients may be discharged from the hospital two hours after
suspected aspiration if they have no new pulmonary symptoms (eg, cough or wheeze) and have normal
oxygen saturation on room air.
Children with mild symptoms who maintain oxygen saturation (SpO2) >90 percent with low level oxygen
supplementation via nasal cannula can be observed on a patient ward. Children who require mechanical
ventilation or high fraction of inspired oxygen should be admitted to the intensive care unit. Recovery in
severe cases may take days to weeks, though death due to aspiration in otherwise healthy children is
extremely rare [15,16].
POSTINTUBATION CROUP — Postintubation croup may occur in the post­anesthesia care unit (PACU) in
recently extubated children. This occurs due to local edema and inflammation caused by pressure of the
endotracheal tube (ETT) on laryngeal or subglottic structures. Even a small amount of edema can cause a
significant increase in airway resistance because of the small internal diameter of the trachea in young
children. Symptoms may include barking cough, inspiratory stridor, suprasternal or subcostal retractions,
respiratory distress, and cyanosis.
Risk factors for postintubation croup — Risk factors include those related to the patient, airway
management, and procedure [17].
Age one to four years old
More than one intubation attempt
Coughing with an ETT in place
Lack of an airway leak with >25 cm H2O airway pressure
Non­supine position or changes in patient position during surgery
Intubation longer than one hour
Prevention of postintubation croup — In all children, an appropriately­sized cuffed ETT should be used to
minimize the need for reintubation for an incorrectly­sized tube. (See "Airway management for pediatric
anesthesia", section on 'Endotracheal tube'.)
The goal for all children should be to achieve a smooth, controlled emergence from anesthesia without
laryngospasm or bronchospasm, oxygen desaturation, coughing, or vomiting. Techniques for emergence and
extubation are discussed separately. (See "Airway management for pediatric anesthesia", section on
'Emergence and extubation'.)
For children who undergo oropharyngeal or neck surgery, or have other risk factors for postintubation croup
(multiple intubation attempts, absence of an airway leak), dexamethasone 0.5 to 0.6 mg intravenous (IV) is
routinely administered intraoperatively. Dexamethasone may also decrease postoperative nausea and
vomiting and pain. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on
'Dexamethasone'.)
Treatment of postintubation croup — Treatment of postoperative croup is primarily based on clinical
experience and the treatment of infectious croup.
Dexamethasone: 0.6 mg/kg IV to a maximum 10 mg, if not given intraoperatively [18].
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Nebulized epinephrine administered over 15 minutes, as follows (see "Croup: Pharmacologic and
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• Racemic epinephrine 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25 percent solution diluted to
3 mL total volume with normal saline OR
• L­epinephrine 0.5 mL/kg per dose (maximum of 5 mL) of a 1:1000 dilution
Racemic and L­epinephrine are equally effective. The treatment may be repeated every 15 to 20 minutes
if necessary.
Disposition after postintubation croup — The effects of racemic epinephrine typically last for two hours
[19], after which symptoms may recur. Children who receive epinephrine should be observed in the hospital
for at least three to four hours after administration. (See "Croup: Pharmacologic and supportive interventions",
section on 'Precautions'.)
Children who at three to four hours are breathing comfortably, without stridor, and have normal oxygen
saturation (SpO2) on room air may be discharged home with instructions to return to the emergency
department if symptoms recur [20,21].
Children who require repeated doses of epinephrine should be admitted to the hospital or intensive care
unit, as indicated, for further monitoring and treatment.
SUMMARY AND RECOMMENDATIONS
Airway and respiratory events (eg, laryngospasm, bronchospasm, aspiration, and perioperative croup)
are the most common perioperative complications in pediatric patients. (See 'Incidence of airway related
complications' above.)
Risk factors for serious airway complications include very young age and multiple intubation attempts.
(See 'Incidence of airway related complications' above.)
Hypoxemia can occur rapidly during airway management, and can lead to bradycardia and cardiac
arrest, particularly in infants. (See 'Hypoxemia' above.)
Laryngospasm occurs more commonly in children than in adults, and can occur during induction,
maintenance, or emergence from anesthesia. (See 'Laryngospasm' above.)
The most important preventive measure is avoidance of airway manipulation during light anesthesia.
Treatment includes administration of 100 percent oxygen by continuous positive airway pressure,
deepened anesthesia, and if necessary, administration of succinylcholine (algorithm 1). (See
'Management of laryngospasm' above.)
Bronchospasm can occur during anesthesia as a result of stimulation from an airway device, aspiration of
gastric contents, anaphylaxis, or underlying reactive airway disease. (See 'Bronchospasm' above.)
Aspiration of gastric contents is a rare complication that can occur during any stage of anesthesia. If
aspiration is suspected, initial management should include the following (see 'Management of aspiration'
above):
• Suction the oropharynx
• Administer 100 percent oxygen by facemask
• Evaluate for and treat bronchospasm and laryngospasm
• For large particle aspiration, summon assistance for possible bronchoscopy
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Subsequent management and disposition depend on the severity of signs and symptoms. (See 'Outcome
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Croup can occur after endotracheal intubation due to local edema and inflammation caused by pressure
of the endotracheal tube (ETT) on laryngeal or subglottic structures. (See 'Prevention of postintubation
croup' above.)
The most important preventive measure is the use of an appropriately­sized ETT. Treatment for
postintubation croup includes administration of dexamethasone 0.6 mg/kg intravenous (IV) to a maximum
of 10 mg, if not administered intraoperatively, and if necessary, administration of nebulized epinephrine.
(See 'Treatment of postintubation croup' above.)
Children who receive nebulized epinephrine should be observed in the hospital for at least three to four
hours after administration. Children who require repeat doses of epinephrine should be admitted to the
hospital for further monitoring and treatment. (See 'Disposition after postintubation croup' above.)
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REFERENCES
1. Mir Ghassemi A, Neira V, Ufholz LA, et al. A systematic review and meta­analysis of acute severe
complications of pediatric anesthesia. Paediatr Anaesth 2015; 25:1093.
2. Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia
(APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir
Med 2017; 5:412.
3. Morray JP, Geiduschek JM, Caplan RA, et al. A comparison of pediatric and adult anesthesia closed
malpractice claims. Anesthesiology 1993; 78:461.
4. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia­related cardiac arrest in children:
update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg 2007; 105:344.
5. Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management complications in children with
difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort
analysis. Lancet Respir Med 2016; 4:37.
6. Olsson GL, Hallen B. Laryngospasm during anaesthesia. A computer­aided incidence study in 136,929
patients. Acta Anaesthesiol Scand 1984; 28:567.
7. Burgoyne LL, Anghelescu DL. Intervention steps for treating laryngospasm in pediatric patients.
Paediatr Anaesth 2008; 18:297.
8. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of adverse events during pediatric
sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric
Sedation Research Consortium. Anesth Analg 2009; 108:795.
9. von Ungern­Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications
in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376:773.
10. Flick RP, Wilder RT, Pieper SF, et al. Risk factors for laryngospasm in children during general
anesthesia. Paediatr Anaesth 2008; 18:289.
11. Lakshmipathy N, Bokesch PM, Cowen DE, et al. Environmental tobacco smoke: a risk factor for
pediatric laryngospasm. Anesth Analg 1996; 82:724.
12. Mamie C, Habre W, Delhumeau C, et al. Incidence and risk factors of perioperative respiratory adverse
events in children undergoing elective surgery. Paediatr Anaesth 2004; 14:218.
13. Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario: perianesthetic management of
laryngospasm in children. Anesthesiology 2012; 116:458.
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14. Walker RW. Pulmonary aspiration in pediatric anesthetic practice in the UK: a prospective survey of
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pediatric
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Anaesth
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15. Borland LM, Sereika SM, Woelfel SK, et al. Pulmonary aspiration in pediatric patients during general
anesthesia: incidence and outcome. J Clin Anesth 1998; 10:95.
16. Warner MA, Warner ME, Warner DO, et al. Perioperative pulmonary aspiration in infants and children.
Anesthesiology 1999; 90:66.
17. Koka BV, Jeon IS, Andre JM, et al. Postintubation croup in children. Anesth Analg 1977; 56:501.
18. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011;
:CD001955.
19. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane
Database Syst Rev 2013; :CD006619.
20. Rizos JD, DiGravio BE, Sehl MJ, Tallon JM. The disposition of children with croup treated with racemic
epinephrine and dexamethasone in the emergency department. J Emerg Med 1998; 16:535.
21. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient
management of croup. Pediatr Emerg Care 1996; 12:156.
Topic 117125 Version 1.0
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GRAPHICS
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Continue or find out more.
Management of laryngospasm in children
CPAP: continuous positive airway pressure; IV: intravenous; IM: intramuscular.
* If succinylcholine is contraindicated, administer rocuronium 1.2 mg/kg IV, or if no IV
access, 1 mg/kg IM in children <1 yr of age, 1.8 mg/kg IM in children >1 year of age;
expect prolonged duration of paralysis.
Adapted from: Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario:
perianesthetic management of laryngospasm in children. Anesthesiology 2012; 116:458.
Graphic 113030 Version 1.0
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Contributor
Disclosures
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or find
out more.
Narasimhan Jagannathan, MD, MBA Continue
Travel support:
Mercury
Medical [Airway (Air-Q)].
Consultant/Advisory Boards: Teleflex [Airway (LMA)]; Vyaire Medical [Nasal oxygenation (SuperNova
Mask)]. Nicholas Burjek, MD Nothing to disclose Carin A Hagberg, MD Grant/Research/Clinical Support:
Ambu [Airway management (Ambu aScope 3, Ambu AuraFlex, Ambu AuraGain, Ambu Aura-I, Ambu
AuraOnce, Ambu AuraStraight, Ambu Aura40, King Vision Video Laryngoscope, King Vision Video
Laryngoscope aBlade System, King LT, King LT-D, King LTS, King LTS-D)]. Consultant/Advisory Boards:
Ambu [Airway management (Ambu aScope 3, Ambu AuraFlex, Ambu AuraGain, Ambu Aura-I, Ambu
AuraOnce, Ambu AuraStraight, Ambu Aura40, King Vision Video Laryngoscope, King Vision Video
Laryngoscope aBlade System, King LT, King LT-D, King LTS, King LTS-D)]. Lena S Sun,
MD Consultant/Advisory boards: Merck [Anesthesia care (Sugammadex)]; Neuorprorexeon. Employment:
Partial salary support to be the Medical Director of SmartTots, a public-private partnership between FDA and
International Anesthesia Research Society. Marianna Crowley, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
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