Professional Documents
Culture Documents
Airway Management
Robert M. Bingham, MB, BS, FRCAa,*,
Lester T. Proctor, MD, FAAPb
a
Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street,
London, WC1N 3JH, UK
b
University of Wisconsin School of Medicine and Public Health, Department of
Anesthesiology, Room B6/319 Clinical Sciences Center, 600 Highland Avenue, Madison,
WI 53792, USA
The pediatric airway and respiratory function differ from those in adults.
Optimum management requires consideration of these differences, but the
application of adult principles is usually sufficient to buy time in an emer-
gency until specialist pediatric help is available. Simple airway opening tech-
niques such as head tilt and jaw thrust are usually sufficient to open the
child’s airway, but there is now a range of equipment available to bypass
supraglottic airway obstructiondthe strengths and weaknesses of such
devices are explored in this article. The role of tracheal intubation is also dis-
cussed, along with the pros and cons of the use of cuffed tracheal tubes in
children, and methods of confirming tracheal placement of the tube.
Scientific background
The etiology of cardiorespiratory arrest differs in children from that in
adults. Most frequently, there is an asphyxial rather than cardiogenic cause;
consequently airway management and pulmonary ventilation are central to
effective pediatric resuscitation. Nowhere is this truer than in the delivery
room, where establishing an airway and providing sufficient ventilation
can reverse neonatal distress in 90% of cases. Children of all ages are
more likely to suffer respiratory compromise and respond to airway and
ventilation maneuvers than are adults.
Emergency airway management of infants and children is evolving. Some
of the basic tenets and dogmas are being challenged, and new equipment
and capabilities are affecting our approach. It is often stated that children,
* Corresponding author.
E-mail address: binghr@gosh.nhs.uk (R.M. Bingham).
0031-3955/08/$ - see front matter Crown Copyright Ó 2008 Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.pcl.2008.04.004 pediatric.theclinics.com
874 BINGHAM & PROCTOR
especially infants and newborns, are not just small adults. There are mor-
phologic differences in airway anatomy, which require changes to manage-
ment and redesign, rather than miniaturization, of equipment. Nevertheless,
children are not a different species, and many adult-based techniques are
applicable; adult-oriented health care providers should not be inhibited
from the emergency care of a child’s airway from fear of doing harm if there
is no pediatric specialist immediately available.
The differences in airway anatomy from adults are particularly marked in
infants. The head shape is completely different in infants compared with
older children and adults. The occiput is protuberant, and the head flexes
on the cervical spine in repose. The tongue is relatively large, and the epi-
glottis relatively longer and thinner. The larynx has a more anterior and
cephalad position, which results in a shortening of the thyromental distance
and consequent ‘‘bunching’’ of the tongue in the oropharynx. The infant
larynx is traditionally described as being cone-shaped, with the narrowest
segment at the level of the cricoid cartilage. This assumption has been chal-
lenged recently, and it is possible that the observations are an artifactual
result of descriptions drawn from cadaveric studies [1]. In any event, the cri-
coid is a complete ring of cartilage, and any mucosal edema here encroaches
on the lumen of the larynx, resulting in large increases in resistance to gas
flow, because flow is proportional to the fourth power of the radius
(Poiseuille’s law).
Developmental changes in the soft tissue structures of the upper airway
occur with age. Radiographic studies [2,3] show that whereas the bony struc-
tures remained proportionately the same size, there is a disproportionate
increase in the size of the adenoidal tissue between 3 and 5 years of age,
resulting in a narrowing of the nasopharyngeal airway at this time. Subse-
quently, bony growth outstrips soft tissue growth, and the airway dimen-
sions increase. An MRI study [4] also demonstrated an increase in
adenoidal size in early childhood, with later regression, but put the age of
maximal adenoid dimension slightly later at 7 to 10 years of age. In contrast,
a further MRI study found that body and soft tissues grow proportionately
through childhood, with airway dimensions increasing steadily with age [5].
The main consequences of all this for emergency airway management are
that, if muscle tone is reduced (as accompanies a reduced level of conscious-
ness), the head will flex and pharyngeal tone is reduced, resulting in reduced
oropharyngeal volume and occlusion of the oropharynx by the tongue.
In this setting, an airway-opening maneuver is required to maintain airway pa-
tency. Modifications to adult-based airway equipment will also be necessary
for neonates and infants, because simply scaled-down equipment may not
be able to provide optimum conditions for airway opening and laryngoscopy.
Differences in pulmonary physiology also affect airway management.
Higher oxygen consumption (6–8 mL/kg/min in infants versus 4–6 mL/
kg/min in adults) and higher ratio of minute ventilation to functional resid-
ual capacity result in far faster falls in arterial oxygen partial pressures if the
AIRWAY MANAGEMENT 875
techniques. One example is the tenet that infants are ‘‘obligate nasal
breathers.’’ Although the anatomy of the infant airway allows better breath-
ing while suckling than does adult anatomy, infants can also maintain an
effective oral airway [14], and open-mouth, jaw-thrust airway maneuvers
are very effective. In addition, the nasopharynx (unlike the oropharnx) is
nondistensible and can easily be occluded. This may explain why mouth-
to-nose ventilation was not superior to mouth-to mouth or mouth-to-nose
and mouth ventilation in infants [15].
In unconscious children, a variety of techniques can be used to open the
airway. In those who have spontaneous respiratory effort, lateral position-
ing may be all that is required [16]. Lateral positioning also improves airway
patency in unconscious children having their airway maintained with simple
airway maneuvers [17]. It is not clear which is the optimum simple airway
maneuver in children [18], although jaw thrust appears superior to simple
positioning in the ‘‘sniffing’’ position [19]. Studies in anesthetized children
have mixed results, with one showing chin lift is equally effective as open-
mouth jaw thrust in improving airway patency [20], and others showing
jaw thrust to be superior [21,22]. Both maneuvers apply anterior tension
to the hyoid bone, which in turn draws the epiglottis away from the poste-
rior pharyngeal wall, opening the pharynx [23]. In addition, the jaw thrust
pulls the tongue away from the palate, also opening the oropharynx.
Thus only the jaw thrust opens both the pharynx and oropharynx. In addi-
tion, the jaw-thrust maneuver can be a potent arousal stimulus, also improv-
ing respiratory effort [24]. Although adult studies suggest that the most
commonly taught jaw-thrust maneuver causes cervical spine motion, the
chin lift does as well [25], because both maneuvers recommend a head tilt.
In patients such as trauma victims, in whom cervical instability may be of
concern, cervical spine immobilization and the use of the minimum head
tilt necessary to open the airway should occur with either maneuver.
CPAP improves airway patency by widening the lateral dimensions of the
airway above the glottis, and preventing collapse of the airway below the
glottis by stenting it open pneumatically [8,20,22,26]. CPAP may also
improve tidal and minute ventilation in spontaneously breathing uncon-
scious children, although by not as much as the jaw thrust [19]. Although
optimal airway management in the relaxed, obstructed airway includes an
open-mouth jaw thrust plus CPAP, the effective application of CPAP usu-
ally requires the use of a flow-inflating (anesthesia) type of bag; personnel
who do not use these regularly are more confident and proficient using
self-inflating bags [27].
In apnoeic children, a two-person bag-mask technique may be more effec-
tive in generating adequate tidal volumes [28], and also creates the opportu-
nity to apply cricoid pressure to prevent regurgitation and limit gastric
distension [29]. In this technique, one rescuer uses both hands to open the air-
way with a jaw thrust and ensure that the mask makes a seal with the face, and
the second rescuer squeezes the bag (and applies cricoid pressure, if required).
AIRWAY MANAGEMENT 877
Airway adjuncts
A number of adjuncts can be use to facilitate an open airway in children.
The simplest of these is the oropharyngeal airway, which is a curved and
flanged tube placed in the oropharynx to bypass the tongue. It is important
to insert the correct size, which can be estimated by lining it up against the
side of the face and ensuring that it extends from the incisors to the angle of
the jaw. Such airways are not tolerated unless there is a low level of con-
sciousness, and attempts to insert one in a child who is resisting can result
in vomiting and laryngospasm. Oropharyngeal airways should always be
inserted with care, because palatal trauma has been reported.
Oropharyngeal airways (OPAs) are occasionally used in conscious new-
borns who have complete nasal airway obstruction (eg, choanal atresia) as
a temporary airway before definitive surgical treatment.
Nasopharyngeal airways are better tolerated at higher levels of conscious-
ness, and have been used for long-term relief of obstructive sleep apnea in
children who have midfacial abnormalities such as in Pierre Robin sequence.
Purpose-made nasopharyngeal airways with a trumpet-shaped flange in-
tended to prevent them migrating into the nose are available (depending on
the manufacturer) down to size 6 mm internal diameter (ID). Below this
size, one can be constructed from a suitable sized tracheal tubedusually
1mm less ID than would be used for tracheal intubation. The length is judged
by measuring from the nose to the external auditory meatus. Once the tube is
cut to length, the connector should be reinserted to prevent loss of the tube
into the nostril. The airway should be inserted in a directly posterior direction
(rather than upwards), and the tube should be well-lubricated and preferably
softened in warm water to minimize nasal trauma. Nasopharyngeal airways
should never be used if there is any suspicion of skull base trauma because
they could introduce infection or even penetrate the anterior cranial fossa
[30].
Tracheal intubation
Despite the earlier comment about the efficacy of bag-mask ventilation
during the initial phase of resuscitation, tracheal intubation offers the
advantages of long-term airway maintenance and protection from aspira-
tion of gastric contents, and the technique is an important part of the further
management of the child’s airway. It is also indicated if airway patency can-
not be achieved by the use of airway maneuvers and adjuncts. A number of
different types of tracheal tube are available (eg, preformed, armored), but
for resuscitation purposes a plain tube made of implant-tested polyvinyl
chloride (PVC) is adequate. Sizes range from 2 to 10 mm ID, and the appro-
priate ID is usually estimated from the formula: age/4 þ 4 (mm ID). This
tends to result in a tube that is slightly too small, so some use age/4 þ
4.5. Tubes one half size larger and smaller should be available in case the
formula does not predict the correct size.
For many years, tracheal tubes without a cuff were routinely recommen-
ded for children. This was based on the anatomy of the infant and small
child’s airwaydthe narrowest part (the cricoid ring) is circular in cross sec-
tion, so a plain tube will create a seal at this level to allow positive pressure
ventilation and prevent ingress of gastric contents. In the older child and
adult airway, where the narrowest part is the hexagonal-shaped glottis, no
seal is possible without a cuff positioned in the trachea. Another concern
in children was that the cuff might cause damage at the cricoid ring and, be-
cause this is a complete ring of cartilage, even a small amount of edema will
result in significant narrowing and very large increases in resistance to flow.
This latter concern was largely based on experience with older type tubes
that used high-pressure cuffs made from irritant materials. Modern
implant-tested tubes with high-volume, low-pressure cuffs have much less
propensity to cause harm.
AIRWAY MANAGEMENT 879
Table 1
Size of laryngeal mask airway related to weight of child and recommended maximum cuff
inflation volume
Size of LMA Weight of patient (kg) Maximum cuff inflation volume (mL)
1 !5 4
1.5 5–10 7
2 10–20 10
2.5 20–30 14
3 30–50 20
AIRWAY MANAGEMENT 881
versions are, however, simply scaled-down versions of the adult devices, and
there is no allowance for the differences in pediatric laryngeal and pharyn-
geal anatomy.
LMAs are useful in adult resuscitation, where they may be a preferable
alternative to bag-mask or mouth-to-mouth ventilation [48]. Although
there are a number of case reports describing the successful management
of supraglottic airway obstruction by experienced operators using LMAs
[49,50], there are currently no published trials of their general use in
pediatric resuscitation. There are good data supporting the safe use of
LMAs in pediatric anesthesia [51,52], but also some evidence that compli-
cation rates are higher, particularly with the smaller sizes [53–56]. There
appears to be a high incidence of impingement of the epiglottis on the
LMA bars following insertion, particularly the size 1 [57]. Complication
rates are also higher for inexperienced users [58], but a recent study
showed that critical care nurses can be successfully trained to use the
LMA in anesthetized children, although time to first breath was slightly
longer than with bag-mask ventilation [59]. A manikin study comparing
LMA ventilation with bag-mask ventilation in prehospital providers found
that time to first breath was greater and that tidal volumes were lower in
the LMA group [60].
There are now a number of other types of LMA such as the intubating
LMA. The intubating LMA is designed to provide a conduit for the blind
passage of a tracheal tube. It is only available for children weighing more
than 25 kg, and although one study reported reasonable success with tra-
cheal tube placement [61], there remains the concern that blind passage of
the tube in the presence of a downfolded epiglottis would result in damage.
Perhaps surprisingly, there is more supporting evidence for the use of the
LMA during resuscitation at birth. Observational studies showed that the
LMA can be used successfully for this purpose and are as effective as
mask ventilation in normal [62,63] and low birth weight [64] babies. A
Cochrane review [65] comparing the use of LMAs with tracheal intubation
in this setting found them to be equally effective, although there was only
one study with small numbers.
Needle cricothyrotomy
The technique of needle cricothyrotomy is commonly taught as the last re-
sort of pediatric airway management. Nevertheless, there are several potential
problems with this technique in children. The cricothyroid membrane is far
less well-defined than in adults, particularly in infants. In addition, the cricoid
ring is the narrowest part of the airway (but see above), and thus a needle
placed just below the thyroid cartilage may not bypass an airway obstruction.
In practice, it may be easier and more effective to insert a needle between two
prominent upper tracheal rings. The largest catheter-over-needle system that
will pass should be used (eg, 14G), but spontaneous ventilation will not be pos-
sible through this catheter. Ventilation must be supported, although positive
pressure ventilation through the catheter does not maintain normocarbia,
and oxygenation is the only realistic goal. The connector from a 3.0 mm (or
3.5 depending on the make) tracheal tube will connect to the luer lock of the
IV cannula, and can be used to connect to a self-inflating bag. Alternatively,
if a continuous oxygen source is available, the tubing can be connected to
a three-way stopcock (with all lumens open), which is in turn attached to
the cannula. With a flow rate of 1 L/min/year-of-age, intermittent occlusion
of the open port of the tap will insufflate gas into the trachea. This latter tech-
nique carries a high risk of barotrauma. Commercial insufflation devices that
provide luer-lock connections and medication ports are available.
Cricothyrotomy is rarely performed, even in adults [70], and data sup-
porting its use in children are absent. Nevertheless there are anecdotal
accounts of individual successes.
Education
Lastly, educational priorities continue to shape the application of the sci-
ence of resuscitation to its implementation. Some known advantageous
techniques may be delayed or discarded because of an inability to effectively
provide them to victims. For instance, although a more secure airway might
appear to be preferable, tracheal intubation does not improve the outcome
of resuscitation compared with bag-mask ventilation in many circumstances
[31]. It seems that the technique of tracheal intubation is too difficult to
teach in the current manner or to be retained long enough for potential ad-
vantages to outweigh the complications of routinely attempting intubation.
Other techniques, such as mouth-to-mouth breathing, are challenged by the
reluctance of potential rescuers to perform them. Rescuers may also be in-
hibited from treating children from the knowledge that there are differences
and fear of doing harm.
By understanding the barriers to performance, it may be that a change in
the approach to training will improve resuscitation outcome by bringing
established interventions to more patients.
AIRWAY MANAGEMENT 883
References
[1] Litman RS, Weissend EE, Shibata D, et al. Developmental changes of laryngeal dimensions
in unparalyzed, sedated children. Anesthesiology 2003;98(1):41–5.
[2] Jeans WD, Fernando DC, Maw AR, et al. A longitudinal study of the growth of the naso-
pharynx and its contents in normal children. Br J Radiol 1981;54(638):117–21.
[3] Fujioka M, Young LW, Girdany BR. Radiographic evaluation of adenoidal size in children:
adenoidal-nasopharyngeal ratio. AJR Am J Roentgenol 1979;133(3):401–4.
[4] Vogler RC, Ii FJ, Pilgram TK. Age-specific size of the normal adenoid pad on magnetic
resonance imaging. Clin Otolaryngol Allied Sci 2000;25(5):392–5.
[5] Arens R, McDonough JM, Corbin AM, et al. Linear dimensions of the upper airway struc-
ture during development: assessment by magnetic resonance imaging. Am J Respir Crit Care
Med 2002;165(1):117–22.
[6] von Ungern-Sternberg BS, Hammer J, Schibler A, et al. Decrease of functional residual
capacity and ventilation homogeneity after neuromuscular blockade in anesthetized young
infants and preschool children. Anesthesiology 2006;105(4):670–5.
[7] Tusman G, Bohm SH, Tempra A, et al. Effects of recruitment maneuver on atelectasis in
anesthetized children. Anesthesiology 2003;98(1):14–22.
[8] Reber A, Geiduschek JM, Bobbia SA, et al. Effect of continuous positive airway pressure on
the measurement of thoracoabdominal asynchrony and minute ventilation in children anes-
thetized with sevoflurane and nitrous oxide. Chest 2002;122(2):473–8.
[9] Vyas H, Milner AD, Hopkin IE, et al. Physiologic responses to prolonged and slow-rise
inflation in the resuscitation of the asphyxiated newborn infant. J Pediatr 1981;99(4):635–9.
[10] Davis PG, Tan A, O’Donnell CP, et al. Resuscitation of newborn infants with 100% oxygen
or air: a systematic review and meta-analysis. Lancet 2004;364(9442):1329–33.
[11] Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation dur-
ing in-hospital cardiac arrest. JAMA 2005;293(3):305–10.
[12] O’Neill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation 2007;
73(1):82–5.
[13] Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening
problem during cardiopulmonary resuscitation. Crit Care Med 2004;32(9 Suppl):S345–51.
[14] Rodenstein DO, Perlmutter N, Stanescu DC. Infants are not obligatory nasal breathers.
Am Rev Respir Dis 1985;131(3):343–7.
[15] 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovas-
cular care science with treatment recommendations. Part 6: paediatric basic and advanced
life support. Resuscitation 2005;67(2–3):271–91.
[16] Litman RS, Wake N, Chan LM, et al. Effect of lateral positioning on upper airway size and
morphology in sedated children. Anesthesiology 2005;103(3):484–8.
[17] Arai YC, Fukunaga K, Hirota S, et al. The effects of chin lift and jaw thrust while in the
lateral position on stridor score in anesthetized children with adenotonsillar hypertrophy.
Anesth Analg 2004;99(6):1638–41 [table of contents].
[18] von Ungern-Sternberg BS, Erb TO, Reber A, et al. Opening the upper airwaydairway
maneuvers in pediatric anesthesia. Paediatr Anaesth 2005;15(3):181–9.
[19] Hammer J, Reber A, Trachsel D, et al. Effect of jaw-thrust and continuous positive airway
pressure on tidal breathing in deeply sedated infants. J Pediatr 2001;138(6):826–30.
[20] Reber A, Paganoni R, Frei FJ. Effect of common airway manoeuvres on upper airway
dimensions and clinical signs in anaesthetized, spontaneously breathing children. Br
J Anaesth 2001;86(2):217–22.
[21] Roth B, Magnusson J, Johansson I, et al. Jaw lift: a simple and effective method to open the
airway in children. Resuscitation 1998;39(3):171–4.
[22] Bruppacher H, Reber A, Keller JP, et al. The effects of common airway maneuvers on airway
pressure and flow in children undergoing adenoidectomies. Anesth Analg 2003;97(1):29–34
[table of contents].
884 BINGHAM & PROCTOR
[23] Reber A, Wetzel SG, Schnabel K, et al. Effect of combined mouth closure and chin lift on
upper airway dimensions during routine magnetic resonance imaging in pediatric patients
sedated with propofol. Anesthesiology 1999;90(6):1617–23.
[24] Drage MP, Nunez J, Vaughan RS, et al. Jaw thrusting as a clinical test to assess the adequate
depth of anaesthesia for insertion of the laryngeal mask. Anaesthesia 1996;51(12):1167–70.
[25] Aprahamian C, Thompson BM, Finger WA, et al. Experimental cervical spine injury model:
evaluation of airway management and splinting techniques. Ann Emerg Med 1984;13(8):
584–7.
[26] Meier S, Geiduschek J, Paganoni R, et al. The effect of chin lift, jaw thrust, and continuous
positive airway pressure on the size of the glottic opening and on stridor score in anesthe-
tized, spontaneously breathing children. Anesth Analg 2002;94(3):494–9 [table of contents].
[27] Mondolfi AA, Grenier BM, Thompson JE, et al. Comparison of self-inflating bags with
anesthesia bags for bag-mask ventilation in the pediatric emergency department. Pediatr
Emerg Care 1997;13(5):312–6.
[28] Davidovic L, LaCovey D, Pitetti RD. Comparison of 1-versus 2-person bag-valve-mask tech-
niques for manikin ventilation of infants and children. Ann Emerg Med 2005;46(1):37–42.
[29] Moynihan RJ, Brock-Utne JG, Archer JH, et al. The effect of cricoid pressure on preventing
gastric insufflation in infants and children. Anesthesiology 1993;78(4):652–6.
[30] Cameron D, Lupton BA. Inadvertent brain penetration during neonatal nasotracheal intu-
bation. Arch Dis Child 1993;69(1 Spec No):79–80.
[31] Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal
intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;
283(6):783–90.
[32] Cooper A, DiScala C, Foltin G, et al. Prehospital endotracheal intubation for severe head
injury in children: a reappraisal. Semin Pediatr Surg 2001;10(1):3–6.
[33] Perron AD, Sing RF, Branas CC, et al. Predicting survival in pediatric trauma patients
receiving cardiopulmonary resuscitation in the prehospital setting. Prehosp Emerg Care
2001;5(1):6–9.
[34] Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed endotra-
cheal tubes in young children during general anesthesia. Anesthesiology 1997;86(3):627–31
[discussion: 627A].
[35] Orliaguet GA, Renaud E, Lejay M, et al. Postal survey of cuffed or uncuffed tracheal tubes
used for paediatric tracheal intubation. Paediatr Anaesth 2001;11(3):277–81.
[36] James I. Cuffed tubes in children. Paediatr Anaesth 2001;11(3):259–63.
[37] Newth CJ, Rachman B, Patel N, et al. The use of cuffed versus uncuffed endotracheal tubes in
pediatric intensive care. J Pediatr 2004;144(3):333–7.
[38] Weiss M, Dullenkopf A, Bottcher S, et al. Clinical evaluation of cuff and tube tip position in
a newly designed paediatric preformed oral cuffed tracheal tube. Br J Anaesth 2006;97(5):
695–700.
[39] Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: a review. Pediatr Emerg
Care 2004;20(5):339–44.
[40] Andersen KH, Hald A. Assessing the position of the tracheal tube: the reliability of different
methods. Anaesthesia 1989;44(12):984–5.
[41] Haynes SR, Morton NS. Use of the oesophageal detector device in children under one year of
age. Anaesthesia 1990;45(12):1067–9.
[42] Sharieff GQ, Rodarte A, Wilton N, et al. The self-inflating bulb as an esophageal detector
device in children weighing more than twenty kilograms: a comparison of two techniques.
Ann Emerg Med 2003;41(5):623–9.
[43] Sharieff GQ, Rodarte A, Wilton N, et al. The self-inflating bulb as an airway adjunct: is it
reliable in children weighing less than 20 kilograms? Acad Emerg Med 2003;10(4):303–8.
[44] Kelly JS, Wilhoit RD, Brown RE, et al. Efficacy of the FEF colorimetric end-tidal carbon
dioxide detector in children. Anesth Analg 1992;75(1):45–50.
AIRWAY MANAGEMENT 885
[45] Bhende MS, Thompson AE, Cook DR, et al. Validity of a disposable end-tidal CO2 detector
in verifying endotracheal tube placement in infants and children. Ann Emerg Med 1992;
21(2):142–5.
[46] Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detector during pediatric car-
diopulmonary resuscitation. Pediatrics 1995;95(3):395–9.
[47] Singh S, Allen WD Jr, Venkataraman ST, et al. Utility of a novel quantitative handheld mi-
crostream capnometer during transport of critically ill children. Am J Emerg Med 2006;
24(3):302–7.
[48] Stone BJ, Leach AB, Alexander CA, et al. The use of the laryngeal mask airway by nurses
during cardiopulmonary resuscitation. Results of a multicentre trial. Anaesthesia 1994;
49(1):3–7.
[49] Yao CT, Wang JN, Tai YT, et al. Successful management of a neonate with Pierre-Robin
syndrome and severe upper airway obstruction by long term placement of a laryngeal
mask airway. Resuscitation 2004;61(1):97–9.
[50] Fraser J, Hill C, McDonald D, et al. The use of the laryngeal mask airway for inter-hospital
transport of infants with type 3 laryngotracheo-oesophageal clefts. Intensive Care Med 1999;
25(7):714–6.
[51] Mason DG, Bingham RM. The laryngeal mask airway in children. Anaesthesia 1990;45(9):
760–3.
[52] Lopez-Gil M, Brimacombe J, Alvarez M. Safety and efficacy of the laryngeal mask airway.
A prospective survey of 1400 children. Anaesthesia 1996;51(10):969–72.
[53] Bagshaw O. The size 1.5 laryngeal mask airway (LMA) in paediatric anaesthetic practice.
Paediatr Anaesth 2002;12(5):420–3.
[54] Park C, Bahk JH, Ahn WS, et al. The laryngeal mask airway in infants and children. Can
J Anaesth 2001;48(4):413–7.
[55] Mizushima A, Wardall GJ, Simpson DL. The laryngeal mask airway in infants. Anaesthesia
1992;47(10):849–51.
[56] Harnett M, Kinirons B, Heffernan A, et al. Airway complications in infants: compar-
ison of laryngeal mask airway and the facemask-oral airway. Can J Anaesth 2000;47(4):
315–8.
[57] Dubreuil M, Laffon M, Plaud B, et al. Complications and fiberoptic assessment of size 1 la-
ryngeal mask airway. Anesth Analg 1993;76(3):527–9.
[58] Lopez-Gil M, Brimacombe J, Cebrian J, et al. Laryngeal mask airway in pediatric practice:
a prospective study of skill acquisition by anesthesia residents. Anesthesiology 1996;84(4):
807–11.
[59] Rechner JA, Loach VJ, Ali MT, et al. A comparison of the laryngeal mask airway with face-
mask and oropharyngeal airway for manual ventilation by critical care nurses in children.
Anaesthesia 2007;62(8):790–5.
[60] Guyette FX, Roth KR, LaCovey DC, et al. Feasibility of laryngeal mask airway use by pre-
hospital personnel in simulated pediatric respiratory arrest. Prehosp Emerg Care 2007;11(2):
245–9.
[61] Weiss M, Schwarz U, Dillier C, et al. Use of the intubating laryngeal mask in children: an
evaluation using video-endoscopic monitoring. Eur J Anaesthesiol 2001;18(11):739–44.
[62] Paterson SJ, Byrne PJ, Molesky MG, et al. Neonatal resuscitation using the laryngeal mask
airway. Anesthesiology 1994;80(6):1248–53 [discussion: 1227A].
[63] Trevisanuto D, Micaglio M, Pitton M, et al. Laryngeal mask airway: is the management of
neonates requiring positive pressure ventilation at birth changing? Resuscitation 2004;62(2):
151–7.
[64] Gandini D, Brimacombe JR. Neonatal resuscitation with the laryngeal mask airway in nor-
mal and low birth weight infants. Anesth Analg 1999;89(3):642–3.
[65] Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal
intubation for neonatal resuscitation. Cochrane Database Syst Rev 2005;(2):CD003314.
886 BINGHAM & PROCTOR
[66] Clayton TJ, Pittman JA, Gabbott DA. A comparison of two techniques for manual ventila-
tion of the lungs by non-anaesthetists: the bag-valve-facemask and the cuffed oropharyngeal
airway (COPA) apparatus. Anaesthesia 2001;56(8):756–9.
[67] Mamaya B. Airway management in spontaneously breathing anaesthetized children: com-
parison of the laryngeal mask airway with the cuffed oropharyngeal airway. Paediatr
Anaesth 2002;12(5):411–5.
[68] Bussolin L, Busoni P. The use of the cuffed oropharyngeal airway in paediatric patients. Pae-
diatr Anaesth 2002;12(1):43–7.
[69] Robbins L, Connelly NR. An evaluation of the cuffed oropharyngeal airway for elective
pediatric anesthesia. J Clin Anesth 2000;12(7):555–7.
[70] Marcolini EG, Burton JH, Bradshaw JR, et al. A standing-order protocol for cricothyrot-
omy in prehospital emergency patients. Prehosp Emerg Care 2004;8(1):23–8.