Airway Management for Laryngotracheal Conditions

Laryngotracheal stenosis comprises a broad spectrum of congenital and acquired conditions that commonly cause pediatric airway obstruction. Although the majority of these conditions were historically managed with endoscopic dilations, the introduction of operative procedures such as laryngotracheoplasty, cricotracheal resection, and slide tracheoplasty changed the treatment paradigm. The gradual evolution of endoscopic technology enabled surgeons to perform certain procedures endoscopically that were previously only able to be performed in an open fashion. Areas covered: This review highlights the important aspects of the diagnosis, workup, and surgical treatment of pediatric laryngotracheal stenosis. Important articles describing research and techniques within pediatric airway reconstruction are summarized and included in the review. Expert commentary: The importance of the multidisciplinary concept of treating laryngotracheal stenosis is evidenced by the establishment of aerodigestive centers internationally. In order to continue successfully treating complex cases of laryngotracheal stenosis, further airway research is needed. The application and feasibility of tracheal transplantation and replacement is likely the next frontier in the treatment of laryngotracheal stenosis.

Airway management is the most important skill of the pediatric anesthesiologist, but what exactly is the pediatric airway? Examined through a broad lens, the pediatric airway is a composite of the anatomic development of the head, face, aerodigestive tract, and neck, structures contiguous as well as integral to the airway. It includes the differentiation of the primitive foregut into the trachea and esophagus and the subsequent development and differentiation of the upper and lower airways. It begins where air enters, normally at the nose and mouth, and is continuous through the upper (extrathoracic) and lower (intrathoracic) conducting airways. The dividing line between the upper and lower airways, the thoracic inlet, is bordered by T1 posteriorly, the first pair of ribs laterally, and the superior border of the manubrium anteriorly. Moreover, consideration of the pediatric airway would be incomplete without including its neurophysiology and gas-flow physics. Beyond that, the very practical details of the equipment needed to care for the pediatric airway are critical for the practitioner. In addition, medical conditions with specific airway challenges beget primary as well as secondary effects that must be accounted for as part of the anesthetic plan. Finally, an exit strategy must be established for patients with normal, and in particular, abnormal airways. The anesthesiologist, in collaboration with the surgeon and perioperative physicians and staff, is a critical stakeholder in that plan. Without elaborating on specific procedures covered elsewhere in this text and others, this chapter explores the developmental perspective on the anatomy and physiology of the upper airways and discusses gas-flow characteristics that change with age and abnormal airway conditions.

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