1. Monitoring by pulse oximetry, to detect airway obstruction, is crucial.

2. The importance of an individualised approach to airway management for assessment or surgery has been stressed (Benjamin & Walker 1991). Several methods have been proposed to overcome the problem of difficult intubation, some under general anaesthesia, and some in the awake patient.The consensus of opinion now seems to favour awake techniques.

a) Asleep technique with a special laryngoscope. Handler and Keon (1983) described a technique for intubation for the anaesthetised spontaneously breathing patient, in which a Jackson anterior commissure laryngoscope is used.The head is elevated above the shoulders, with flexion of the lower cervical vertebrae and extension at the atlanto-occipital joint. The laryngoscope is introduced into the right side of the mouth. Only the tip is directed towards the midline, the proximal end remaining laterally, so that a further 30 degrees of anterior angulation can be obtained. The narrow, closed blade prevents the tongue from falling in and obscuring the view of the larynx. When visualised, the epiglottis is elevated, and the larynx entered. Intubation is then achieved by passing a lubricated tube, without its adaptor, down the laryngoscope. It is held in place with alligator forceps whilst the laryngoscope is withdrawn.

i b) Asleep technique in the prone position. The appreciation of the problems in the supine position led to the description of a ® successful blind nasal intubation with the o patient prone (Populaire et al 1985).This S position allows the tongue and mandible d to fall forward under the effect of gravity ^ and leave the larynx exposed. ®

c) Fibreoptic bronchoscopic techniques.A variety of fibreoptic techniques have been described (Howardy-Hansen & Berthelsen 1988, Scheller & Schulman 1991, Sher 1992). In small infants, the 'tube over bronchoscope' technique is not always possible because of the small size of the tube, therefore a Seldinger type approach may be necessary (paediatric bronchoscopes of 2.5 mm diameter are now available, but their very fineness makes them less easy to handle than the 4-mm bronchoscopes).After the administration of atropine, ketamine im, and topical lidocaine (lignocaine), a fibreoptic bronchoscope (OD 3.6mm, L 60 cm, and suction channel 1.2 mm) was passed through one nostril.The tongue was held forward with Magill forceps, until the vocal cords were seen, but not entered, because of the risk of total obstruction. Under direct vision, a Teflon-coated guidewire with a flexible tip was passed via the suction channel into the trachea.The bronchoscope was carefully removed leaving the wire in place, and a 3-mm nasotracheal tube then passed over it into the trachea.

d) Awake techniques using a special laryngoscope. The use of a special purpose, slotted laryngoscope (Holiger paediatric anterior commissure laryngoscope Karl Storz, Tuttlingen, FRG) has been described (Benjamin & Walker 1991).

e) Laryngeal mask techniques.The use of a laryngeal mask airway to guide an introducer for subsequent intubation was used as an emergency (Chadd et al 1992,

Baraka 1995), and electively (Hansen et al 1995, Osses et al 1999, Selim et al 1999). Elective placement of the laryngeal mask airway following topical anaesthesia in three awake infants has been described (Markakis et al 1992).

f) The use of a lighted stylet (Cook-Sather & Schreiner 1997).


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