Related Experiment Video
Updated: Jun 9, 2025
Author Spotlight: Advancing Awake Nasotracheal Intubation with Flexible Video Rhino-Laryngoscopes
Published on: August 2, 2024
Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights
Mckenna Longacre1,2, Raymond S Park1,2, Steven J Staffa1
1From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
Insights
Awake supraglottic airway placement in children with difficult airways is effective for ventilation and oxygenation. This procedure, though rarely used, demonstrates good outcomes across various pediatric age groups.
Area of Science:
- Pediatric Anesthesiology
- Airway Management
- Critical Care
Background:
- Difficult airway management in children presents unique challenges.
- Previous studies on awake supraglottic airway placement are limited to small case series.
- The Pediatric Difficult Intubation Registry offers a valuable dataset for rare airway procedures.
Purpose of the Study:
- To evaluate the outcomes of awake supraglottic airway (SGA) placement in children with difficult airways.
- To assess ventilation success, tracheal intubation success, and complication rates.
- To analyze the efficacy of SGA as a conduit for oxygenation and ventilation in awake pediatric patients.
Main Methods:
- Retrospective review of the Pediatric Difficult Intubation Registry (August 2012 - September 2023).
- Identification of cases involving awake SGA placement prior to planned tracheal intubation.
- Descriptive statistical analysis of patient demographics, procedural outcomes, and complications.
Main Results:
- Awake SGA placement occurred in 1.2% (95/8061) of registry cases, with a median age of 37 days.
- Adequate ventilation was achieved in 85% of cases; inadequate/impossible ventilation occurred in 15%.
- No complications were reported; first-attempt tracheal intubation success was 35%, with 99% eventual success. Hypoxia incidence was lower with adequate SGA ventilation.
Conclusions:
- Awake supraglottic airway placement in children with difficult airways is a viable option for maintaining oxygenation and ventilation.
- The procedure is effective across a wide range of pediatric ages, including infants and adolescents.
- SGA placement in awake, difficult airway patients facilitates subsequent tracheal intubation with a high success rate.
Background:
Small case series have described awake supraglottic airway placement in infants with significant airway obstruction and difficult intubations. We conducted this study to determine outcomes when supraglottic airways were placed in awake children enrolled in the international Pediatric Difficult Intubation Registry including success of ventilation, success of tracheal intubation, and complications.
Methods:
We reviewed the Pediatric Difficult Intubation Registry to identify all cases of awake supraglottic airway placement before planned tracheal intubation from August 2012 to September 2023 with subsequent review of details of awake supraglottic airway placement in the medical record. We present descriptive statistics of patient demographics, ventilation and intubation outcomes, and complications.
Results:
A supraglottic airway was placed in an awake child in 95 of 8061 (1.2%) cases in the Pediatric Difficult Intubation Registry. Median age was 37 days (range 0-17.6 years) and median weight was 3.7 kg (1.6-46.7 kg). Sixteen (17%) cases were in patients older than 2 years and 7 (7%) were in adolescents. Adequate ventilation via a supraglottic airway was achieved in 81/95 (85%, 95% confidence interval [CI], 77%-93%) encounters. Inadequate (n = 13) or impossible (n = 1) ventilation occurred in 14/95 (15%). No complications were reported with supraglottic airway placement. For subsequent intubation, there was a 35% (33/95) first-attempt success rate and 99% (94/95) eventual success, with 1 patient awakened after failed attempts at tracheal intubation. Hypoxia occurred during the first intubation attempt in 9/95 (9%) encounters. The incidence of hypoxia was lower in encounters in which ventilation via the supraglottic airway was adequate (4/81, 5%) than in encounters in which ventilation via the supraglottic airway was inadequate or impossible (5/14, 36%).
Conclusions:
Although infrequently attempted, awake placement of a supraglottic airway in children with difficult airways achieved adequate ventilation and provided a conduit for oxygenation and ventilation after induction of anesthesia across a spectrum of ages.
Related Concept Videos
01:30Cardiopulmonary Resuscitation V: Advanced Airway Management Techniques
01:22Cardiopulmonary Resuscitation II: ACLS Airway Management
01:15Endotracheal Intubation I: Procedure
The ET tube comprises various components, including a standard adaptor to attach a bag-valve-mask (BVM) or ventilator, a cuff, a pilot balloon, and radiopaque markings along its length to measure the insertion distance. The tube sizes...
01:24Endotracheal Tube Extubation
Procedure
Extubation removes the endotracheal tube (ETT) from the patient on mechanical ventilation. It requires a well-coordinated, multidisciplinary approach involving physicians, nurses, respiratory therapists, and other healthcare professionals....
01:17Endotracheal Intubation II: Nursing Management
1. Nursing Care of Patients Before Intubation
Before the endotracheal intubation procedure, nurses play an essential role in ensuring the process goes smoothly. The nurses must be familiar with intubation...
01:26Tracheostomy Suctioning I: Pre-Procedural Steps
Equipment Required
First, gather all necessary equipment: a sterile suction catheter, a sterile disposable container, sterile gloves, a towel or...