Paediatric airway management: basic aspects

Review Article

Paediatric airway management: basic aspects

R. J. HOLM-KNUDSEN and L. S. RASMUSSEN

Department of Anaesthesia, Center of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

Paediatric airway management is a great challenge, espe-cially for anaesthesiologists working in departments witha low number of paediatric surgical procedures. Thepaediatric airway is substantially different from the adultairway and obstruction leads to rapid desaturation ininfants and small children. This paper aims at providingthe non-paediatric anaesthesiologist with a set of safe andsimple principles for basic paediatric airway management.In contrast to adults, most children with difficult airwaysare recognised before induction of anaesthesia but pro-blems may arise in all children. Airway obstruction can beavoided by paying close attention to the positioning of the

head of the child and by keeping the mouth of the childopen during mask ventilation. The use of oral and naso-pharyngeal airways, laryngeal mask airways, and cuffedendotracheal tubes is discussed with special reference tothe circumstances in infants. A slightly different techniqueduring laryngoscopy is suggested. The treatment of airwayoedema and laryngospasm is described.

Accepted for publication 21 August 2008

r 2008 The AuthorsJournal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation

AIRWAY-RELATED problems are among the mostcommon perioperative critical incidents in

paediatric anaesthesia, and in infants youngerthan 1 year of age these are four times morecommon than in older children.1 Knowledge aboutand training in paediatric airway management istherefore mandatory.

The purpose of this paper is to describe someof the differences between the paediatric andadult airway and to suggest principles for basicpaediatric airway management, coveringpositioning, mask ventilation, inhalational induc-tion, use of supraglottic airways, endotracheal in-tubation, and tracheal extubation. The preventionand treatment of airway oedema and laryngos-pasm are also described. Even small changes inthe practical management can make a huge differ-ence and it is the aim of this paper to supply thenon-paediatric anaesthesiologist with some usefulpractical hints that may provide a set of safe andsimple principles.

Preparation and pre-operativeevaluation

A careful medical history related to airway pro-blems should be obtained before anaesthetising a

child. The parents may have observed signs of adifficult airway such as excessive snoring and sleepapnoea, or they may present a history of problemsduring previous anaesthesia. In contrast to adults,most children with difficult airways are recognisedbefore induction of anaesthesia. Syndromes withface malformations, especially those with a shortmandible and ear deformity, should alert the anaes-thetist, as these are often associated with difficultairways.

Differences between the paediatric andadult airway

The airway in infants and small children is verydifferent from the airway in older children andadults. Obviously, the size is smaller, which itselfmay make things slightly more difficult, but otherfactors must also be taken into consideration dur-ing airway management in small children as sum-marised in Table 1. The difficulties can result inairway obstruction and apnoea. Unfortunately,the oxygen reserve is much smaller because of alow functional residual lung capacity and higheroxygen consumption. Desaturation therefore oc-curs much more rapidly.

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Acta Anaesthesiol Scand 2009; 53: 1–9Printed in Singapore. All rights reserved

r 2008 The Authors

Journal compilation r 2008 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2008.01794.x

Positioning

Head positioning is extremely important duringairway management in small children. The optimalposition is obtained when the neck is in a neutral ora slightly extended position (Fig. 1). The head, andespecially the back of the head, is relatively large,and the younger the child is, the more pronouncedthis is. Therefore, in neonates and premature chil-dren, airway management should be performedwith a small towel under the shoulders to avoidflexion of the neck. A foam ring to stabilise thehead may cause neck flexion that makes airwaymanagement more difficult, but this can be com-pensated for by placing gel pads or similar objectsunder the back of the child.

Mask ventilation

Many different types of face masks are available onthe market. A transparent, disposable mask with alarge and soft cuff is recommended, as this featuremakes it very easy to establish an airtight seal to theface. At the same time, the transparency is useful,and the children seem to find them less frighteningthan the black masks. It is important to choose aface mask large enough to allow the mouth of thechild to be open during ventilation, but at the sametime the mask should not cover the eyes of thechild (Fig. 2). The tongue falls back when the childis anaesthetised and this tends to obstruct theairway. Obstruction is best avoided if the mouthis kept open during mask ventilation. This isaccomplished by pressing the distal cuff of themask against the chin. No pressure should beapplied against the floor of the mouth, as this willpress the tongue against the palate and airwayobstruction may result.

It may be helpful to show the face mask to thechild before mask induction. If the mask is wavedin front of the infants, their natural instinct is tograb for the mask and ‘taste’ it, thereby facilitatinginduction.

The older child may realise that the face mask isnot that scary, and most of the older anxiouschildren feel safer, and they may cooperate better,if they hold the face mask themselves. In anxiouschildren, it is recommended to initially administer70% nitrous oxide in oxygen, while telling a storyas a ‘fantasy journey’. The ‘fantasy journey’ is an

Table 1

Differences between the adult and paediatric airway.

Dimensions smallerHead relatively larger in infantsTongue relatively largerShort JawPalate longLong EpiglottisLarynx located more cephaladVocal cords angled more anteriorlyAirway narrowest at the cricoid cartilageAirway softAirway more reactive and infants more prone to developlaryngospasm.

Fig. 1. The optimal position for airway management is with thehead in a neutral or slightly extended position. In prematurechildren, a small towel under the shoulders is helpful.

Fig. 2. The face mask should be large enough to allow the mouth ofthe child to be open during ventilation, but at the same time itshould not cover the eyes of the child.

R. J. Holm-Knudsen and L. S. Rasmussen

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interactive story in which the child participates(e.g. riding a bike or a motorbike or swimmingamong dolphins). After a couple of minutes, sevo-flurane 0.2–0.3% is added for 20–30 s, after which,the concentration can be quickly increased to 6–8%.

Airway muscle tonus is always decreased duringinhalational induction and some degree of obstruc-tion frequently occurs. Twisting movements of theextremities are often an early sign of partial airwayobstruction, and the basic technique should bereviewed; i.e. head position, open mouth, and nopressure under the chin. A chin lift or a jaw thrustmay be helpful. The mouth of the child should beopened widely if airway obstruction is not imme-diately relieved. Quite often, it will be observedthat the tongue is pressed against the palate andthe wide mouth opening will release the tonguefrom the palate and restore the open airway.

Some children continue to obstruct despite acorrect technique. This is most commonly seen inchildren who also obstruct during sleep. This maybe caused by hypertrophic tonsils, airway malacia,or other conditions with narrow or soft airways. Inthese children, it is useful to apply assisted ventila-tion with CPAP, 10–15 cm of water, by slightlysqueezing the ventilation bag during the expirationphase, thereby expanding the airway.

If the described techniques are used, supraglotticairway devices are rarely needed. An oral or a nasalairway may be used, but the risk of eliciting alaryngospasm should be kept in mind. The detectionand management of laryngospasm is described later.

Gastric air insufflation is very common duringmask ventilation in infants, and the stomach shouldalways be emptied after mask ventilation. This isespecially important if ventilation has been difficultor the anaesthesiologist is not very experiencedwith ventilating small children. Severe gastric dis-tension grossly impairs the movement of the dia-phragm and ventilation may be almost impossibleif this occurs. In this situation, the stomach must bevented to allow adequate ventilation. In prematureinfants with low lung compliance, mask ventilationmay easily be accomplished by using small tidalvolumes and a very high respiratory rate.

Supraglottic airway devices

An oral airway prevents the tongue from pressingagainst the palate and creates a passage for ventila-tion. It is important that the oral airway has exactlythe correct length, which is estimated by holding it

against the cheek of the child. The tip of the airwayshould reach distal to the angle of the jaw. If theoral airway is too short, it will displace the tongueand obstruct the airway, and if it is too long, it mayprecipitate laryngospasm, as anaesthesia is oftenlight, when the oral airway is needed. As men-tioned earlier, if the mouth is kept open duringmask ventilation, the oral airway is only rarelyneeded.

A nasopharyngeal airway rarely causes laryn-gospasm, even if it is inserted during light levels ofanaesthesia. Ordinary uncuffed endotracheal tubesare most useful. The advantage is the possibility toconnect the anaesthetic circuit directly to the ‘nasalairway’ when in place. It is advisable to use asuction catheter as a guide, when the nasal airwayis passed through the nose, to avoid bleeding. Thesize of the ‘nasal airway’ should be smaller thanwhen used for endotracheal intubation. Size 3.0 isappropriate in newborns, and nasal airways 44.5or 5.0 are not necessary for this purpose even inlarger children. The optimal insertion depth isestimated by listening to the breathing sounds inthe ‘nasal airway’. In the first year of life, this depthis 8 � 0.5 cm and in the second year it is8.5 � 0.5 cm.2

The nasal airway is also a useful device indifficult upper airways or in the case of a difficultface mask fit.2 It is possible to assist or controlventilation via the nasal airway if the mouth andthe free nostril are closed manually.

Laryngeal mask airways (LMA)

LMA are widely used in children. In many situa-tions, it is an acceptable alternative to endotrachealintubation and its usefulness in difficult airways iswell documented. The choice of the LMA is basedon the lean body weight of the child (Table 2). TheLMA is usually easy to insert in children, but ininfants the long epiglottis is frequently caught anddown-folded by the tip of the LMA. Therefore,many paediatric anaesthetists prefer to insert thesmaller LMA in a reverse fashion, with the opening

Table 2

Laryngeal mask airway sizes.

o5 kg #15–10 kg #1.5

10–20 kg #220–30 kg #2.530–50 kg #3

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of the mask against the palate, and then rotate itin place when it is fully inserted.3 This techniquecan only be used in LMA with a rigid tube. It iscommon to inflate the cuff partly during insertion.The amount of air in the cuff should keep itexpanded but not distended. When the LMA is inplace, the pilot cuff should be soft, and aspirationof some of the air may be needed, but with thistechnique, it should not be necessary to inflate thecuff further. If there is a leakage around the LMA, itis probably misplaced or too small. It is importantto make sure that the LMA does not displace fromthe central position. Otherwise, the risk of airinsufflation of the stomach increases during con-trolled ventilation.4 Displacement and airway ob-struction occur most frequently with the smallestLMA, and size #1 should probably only be used forshort procedures by experienced users.5 Trachealintubation is preferred with longer procedures. Sofar, it seems wise not to connect a ventilator, whenthe smallest LMAs are used. We do not use aventilator when a size #2 LMA or less is used,corresponding to children weighing o20 kg. At theend of anaesthesia, the child is positioned on theside if possible. When spontaneous ventilation issufficient the LMA is removed. If the cuff is notdeflated before removal, more secretions are re-moved with the mask. The timing of removal isdebated, but it is recommended to remove theLMA rather early, before the return of reflexes.

Endotracheal intubationWhen infants and small children are intubated,several conditions differ from older children. Thetongue is relatively large and takes up more of thespace in the oral cavity. At the same time, the jaw isshorter, making it more difficult to displace thetongue. The larynx is located higher in the neck,and in newborns the laryngeal inlet is as cephaladas the second cervical vertebra.

The epiglottis is long, narrow, omega-shaped,and angled into the lumen of the airway coveringthe laryngeal inlet. This and the cephalad positionof the larynx often make it difficult to visualise thelaryngeal inlet by conventional laryngoscopy. Thehigh location of the larynx also means that ‘thesniffing position’ is of no benefit in small children,and a pillow under the large head only makesairway management more difficult by flexing theneck. During the first years of life, the larynx movesdistally until the age of four, when it is located atthe adult level at C5–C6.

Until the age of 10–12 years, the narrowestportion of the airway is at the level of the cricoidcartilage, which is a ring of cartilage, which is whythe airway at this point is rigid and not distend-able. Therefore, an endotracheal tube that easilypasses the vocal cords may still be too large, andforcing it through the cricoid ring will compressand traumatise the mucosa. The airway in smallchildren is very vulnerable, and airway oedemaand post-intubation stridor is easily induced. Sub-sequent tracheal scarring and stenosis may follow,although this is very uncommon.

Airway trauma can be reduced by careful in-strumentation and by using an endotracheal tubeof an appropriate size. The tube must not be forcedinto the trachea, and if a cuffed tube is used, thecuff pressure should be monitored and kept as lowas possible. If a cuff pressure 430 cm of water isnecessary to avoid leakage of air, changing to alarger tube should be considered. The tube shouldbe firmly secured to avoid the tip of the tube tomove up and down in the trachea. Likewise, move-ment of the head should be minimised.

In the smallest children, airway oedema willhave the most impact due to the smaller dimen-sions.

The estimated size of the endotracheal tube canbe chosen from a table (Table 3) and compared withthe distal phalanx of the fifth finger of the child,which often correlates well with the tube size. Fromthe age of 2 years, the formula Tube size 5 41(age/4), may be used as guidance. If cuffed tubes areused, the formula is changed to 3.51(age/4).

The use of cuffed tubes has been shown to resultin fewer reintubations due to ill-fitting tubes, and itis not associated with more cases of post-intubationstridor, as long as cuff pressure was monitored andkept as low as possible.6 For laryngoscopy twomain types of laryngoscope blades exist: thestraight, Miller-type blade or the curved MacIn-tosh-type blade. Both types may be used in thesame way and the type chosen is a matter ofpreference. The MacIntosh blade can be used inchildren weighing 42–2.5 kg. The smaller size of

Table 3

Endotracheal tube sizes.

Uncuffed Cuffed

Newborn o3 kg 3.0 –Newborn 3.5 3.04 months 4.0 3.512–16 months 4.5 4.0


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the Miller blade is an advantage in children belowthis weight.

Because of the long epiglottis and the cephaladlocation of larynx it is usually necessary, during thefirst year of life, to apply external pressure on theneck to bring the laryngeal aperture into vision.The exact location and force of pressure neededcannot be explained to an assistant, and you shouldbe able to apply this pressure yourself by using thefifth finger of the hand holding the laryngoscope.To do this it is crucial not to hold too distally on thehandle. The palm of the left hand should rest on thehead of the child, and the first finger should nottouch the handle of the laryngoscope, but be placedon the proximal end of the blade. In this way, thefourth and fifth finger can easily be used to applypressure in the right place on the neck of the child,while the second and third finger may be used tosupport the handle (Fig. 3).

During laryngoscopy, the tongue should bemoved to the left by the laryngoscope andthe blade should be introduced gradually into themidline until the epiglottis is seen. The tip of theblade is then advanced further against the valleculaat the base of the epiglottis. The best view wouldoften be like in Fig. 4A, where the epiglottis iscovering the laryngeal aperture. Even though theMiller blade was designed to lift up the epiglottis,this should not be done routinely, as it may pre-cipitate bradycardia. Instead, an external pressuremay be applied over the larynx with the fifth finger,which will flip up the epiglottis and bring the vocalcords into view (Fig. 4B).

When the vocal cords are visualised, the endo-tracheal tube is inserted between them, and with-

out use of force, it is then moved through thecricoid cartilage. In infants, the vocal cords areangled more anteriorly, and if the tip of the tubeis caught in the anterior commisure, a slightlyrotating movement of the tube will often solvethe problem. It is important not to obstruct theview to the larynx during intubation to be able tovisually control how far into the trachea the tube isinserted. As soon as the tube is in place, thecentimetre marking near the gingiva or teeth isnoticed. In this way, it is possible to re-establish theposition of the tube, if it is accidentally movedduring fixation. In premature children or othersituations when a very accurate location of the tipof the endotracheal tube is critical, another techni-que may be helpful. During ventilation, the endo-tracheal tube is slowly advanced further, while at

Fig. 3. Laryngoscope grip in order to be able to apply pressure onthe neck with the fifth finger. The first finger should not touch thehandle of the laryngoscope, but be placed on the proximal end of theblade.

Fig. 4. (A) Glottic view without applying external pressure on thelarynx. (B). Glottic view with a slight pressure on larynx with thefifth finger.

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the same time listening for the breath sounds in theleft axilla. When the breath sounds disappear, thetube tip would have reached the right mainbronchus, after which it is retracted, until thesounds return. If the sounds do not disappear,the tube has entered the left main bronchus, andthe procedure is repeated while listening in theright axilla.

In a few children, the intubation may be toodifficult to allow you to manipulate and applyenough external pressure on the neck with the fifthfinger. Instead of trying to instruct an assistant onhow to manipulate and apply pressure on the neck,it is better to use both your hands to visualise thecords. When the view is, ‘as good as it gets’, keepthe hands still, move your head out of the way, andlet the assistant introduce the endotracheal tube(Fig. 5). This two-anaesthetist intubation is a veryuseful procedure, which has saved many days inboth paediatric and adult practice. If, despite usingthis technique, only the epiglottis is seen, thenfibre-optic intubation or ‘look-around-corner-de-vices’ should be considered.

Tracheal extubation

Before extubation, the child should be on sponta-neous ventilation. Whether it should be performedduring deep anaesthesia or in the awake state isprobably a matter of preference, but it is alsoinfluenced by the actual circumstances. After air-way surgery, if the anaesthesiologist has less pae-diatric experience, or if the airway was difficult to

handle during induction, extubating in the awakepatient is preferable and associated with fewerairway complications such as laryngospasm.

A good extubation strategy is, before anaesthesiabecomes too light, to turn the child on the sidefacing away from you, making it possible to stabi-lise the child against your body, and administeroxygen via a face mask after extubation if neces-sary. There should be no pillow under the head,making the trachea the uppermost part of theairway. In this way, secretions and blood will drainaway from the larynx and run out the mouth.

Now leave the child completely undisturbeduntil ready for extubation. After sevoflurane anaes-thesia, this is the case if the child makes purposefulmovements or the expired concentration of sevo-flurane is 0.3%. The circuit is filled with 100%oxygen and, without separating the anaestheticcircuit from the endotracheal tube, the extubationis performed during inspiration, while applyingpressure on the ventilation bag. In this way, thechild will receive a maximal inspiration just beforeextubation, and when the endotracheal tube leavesthe trachea, the air will escape in a forceful expira-tion that will remove any residual secretions fromthe larynx. Use of this technique, while the child islying on the side, makes suctioning before extuba-tion unnecessary.

Airway oedema treatment

If the intubation turned out to be more difficult andtraumatic than expected, it may be wise to admin-ister intravenous (i.v.) steroids prophylactically toreduce the risk of airway oedema and post-intuba-tion stridor. We suggest dexamethasone 0.6 mg/kgup to a maximum of 12 mg.

If stridor is present after extubation, adrenalininhalation very effectively reduces the swelling. Arather high dose of L-adrenaline or racemic adrena-line can be used without significant side effects andour protocol includes L-adrenaline 0.5 mg/kg(maximum 6 mg). If racemic adrenaline is usedthe dose should be doubled. The treatment shouldbe repeated at increasing intervals to avoid recur-rence of the stridor.

Breathing a helium–oxygen mixture reduces thestridor instantaneously by lowering the viscosity ofthe air and may buy some time, until the effect ofthe steroids sets in. The helium concentration mustbe as high as possible and at least above 60% tohave any clinical effect. Quite often, though, it is

Fig. 5. Two-anaesthetist intubation. One person performs laryn-goscopy and external manipulation of larynx to optimise theintubation condition, while a second person inserts the endotra-cheal tube.


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difficult to ‘persuade’ the stressed and anxiouschild to breath the mixture, which is why reintuba-tion may be the necessary and safest approach.

Laryngospasm

Laryngospasm consists of a powerful and pro-longed contraction of the glottic and supraglotticlaryngeal adductor muscles. The result is closure ofthe vocal cords and the false cords, and infolding ofthe arytenoid region, which effectively seals off the

larynx at three levels (Fig. 6). During completelaryngospasm it is not possible to force oxygenthrough the larynx or to intubate the child withoutinjuring the airway. On the contrary applyingexcessive airway pressure may make the larynxwork like a ball valve and thereby maintain theobstruction.

Laryngospasm is most commonly caused bysecretions or blood in the airway during inductionor awakening, but may also be elicited by systemicpainful stimulation during maintenance, if theanaesthesia is too light.

Fig. 6. Larynx before and during a laryngospasm. White, movement of the vocal cords; yellow, movement of false cords; blue, movement ofarytenoids.

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Several risk factors for laryngospasm have beenidentified (Table 4).7,8

Even though the spasm will alleviate in the enddue to hypoxia, it is not recommended to waittoo long before interacting, as post-obstructionpulmonary oedema or even cardiac arrest mayresult.9,10

If laryngospasm occurs, the first treatmentshould be oxygen delivered by a tight-fitting facemask applied with moderate intermittent pressure.If a high-pitched stridor is heard, it means that thespasm is partial and some oxygen can enter thelungs. A firm jaw-trust may stretch the larynx andhelp alleviate the spasm. During induction, anincomplete spasm will also allow anaesthetic gasesto deepen the level of anaesthesia.

If the laryngospasm is complete, no air will enterthe lungs, but oxygen should still be given by a facemask in order to be ready as soon the spasmalleviates. Propofol in small doses has been shownto alleviate the spasm in 75% of cases.11 If it is readyin a syringe 1–2 mg/kg is given i.v., depending onwhether the spasm occurs during induction orawakening. Otherwise, the most effective treatmentis succinylcholine i.v. Doses as small as 0.1 mg/kgi.v. have been shown to relieve the spasm and0.25–0.3 mg/kg i.v. will quickly relieve the spasmwhile allowing the child to continue spontaneousbreathing.12 Succinylcholine 4–5 mg/kg may begiven intramuscularly if i.v. access has not yetbeen established. The site of injection should becentral, i.e. in the pectoral or the deltoid muscle,followed by massage of the injection site. This willact rapidly, as the laryngeal muscles are verysensitive to the muscle relaxant, and only a smallfraction has to be absorbed to alleviate the spasm.

Children with an increased risk of laryngospasmshould be anaesthetised by experienced staff and ano-touch technique applied during recovery. Pro-pofol 0.5 mg/kg given i.v. 60 s before extubation

also reduces the risk.13 In small children, atropinemay help by reducing secretions and attenuatingvagal reflexes.

Conclusion

Paediatric airway management is a great challenge,especially for anaesthesiologists working in de-partments with a low number of paediatricsurgical procedures. Strict adherence to safe andsimple principles can definitely affect the confi-dence and outcome. It is essential to pay attentionto the details described in this paper, such aspositioning of the head of the child, keeping themouth of the child open during mask ventilation,the appropriate use of supraglottic airways, andusing an optimal technique during tracheal intuba-tion and extubation.

Acknowledgement

Figures also appear in ‘Børneanæstesi’, edited by Tom G.Hansen and Steen W. Henneberg, FADL’s forlag 2008. Textpartly based on Danish chapter in that book.

References

1. Tay CLM, Tan GM, Ng SBA. Critical incidents in paediatricanaesthesia: an audit of 10 000 anaesthetics in Singapore.Pediatr Anesth 2001; 11: 711–18.

2. Holm-Knudsen R, Eriksen K, Rasmussen LS. Using anasopharyngeal airway during fiberoptic intubation insmall children with a difficult airway. Pediatr Anesth 2005;15: 839–45.

3. Ghai B, Makkar JK, Bhardwaj N, Wig J. Laryngeal maskairway insertion in children: comparison between rota-tional, lateral and standard technique. Pediatr Anesth 2008;18: 308–12.

4. Wahlen BM, Heinrichs W, Latorre F. Gastric insufflationpressure, air leakage and respiratory mechanics in the useof the laryngeal mask airway (LMAt) in children. PediatrAnesth 2004; 14: 313–7.

5. Park C, Bahk JH, Ahn WS, Do SH, Lee KH. The laryngealmask airway in infants and children. Can J Anaesth 2001; 48:413–7.

6. Khine HH, Corddry DH, Kettrick RG, Martin TM, McClos-key JJ, Rose JB, Theroux MC, Zagnoev MMB. Comparisonof cuffed and uncuffed endotracheal tubes in young chil-dren during general anesthesia. Anesthesiology 1997; 86:627–31.

7. Mamie C, Habre W, Delhumeau C, Argiroffo CB, MorabiaA. Incidence and risk factors of perioperative respiratoryadverse events in children undergoing elective surgery.Pediatr Anesth 2004; 14: 218–24.

8. Skolnick ET, Vomvolakis MA, Buck KA, Mannino SF, SunLS. Exposure to environmental tobacco smoke and the riskof adverse respiratory events in children receiving generalanesthesia. Anesthesiology 1998; 88: 1144–53.

Table 4

Risk factors for occurrence of laryngospasm.

Low ageUpper airway inflammation, actual or recentlySurgical procedure involving the airwayExposure to smoking in the homeAnaesthetist with low experience in paediatric anaesthesiaEndotracheal intubation without use of muscle relaxantAsthmaThiopentone4sevoflurane4propofol for inductionEndotracheal intubation4LMA4face mask

LMA, laryngeal mask airways.


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9. Olsson GL, Hallen B. Laryngospasm during anaesthesia. Acomputer-aided incidence study in 136 929 patients. ActaAnaesthesiol Scand 1984; 28: 567–75.

10. Alalami AA, Ayoub CM, Baraka AS. Laryngospasm: re-view of different prevention and treatment modalities.Pediatr Anesth 2008; 18: 281–88.

11. Afshan G, Chohan U, Qamar-Ul-Hoda M, Kamal RS. Isthere a role of a small dose of propofol in the treatment oflaryngeal spasm? Pediatr Anesth 2002; 12: 625–8.

12. Chung DC, Rowbottom SJ. A very small dose of suxa-methonium relieves laryngospasm. Anaesthesia 1993; 48:229–30.

13. Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR,Belani KG. The efficacy of a subhypnotic dose of propofol

in preventing laryngospasm following tonsillectomy andadenoidectomy in children. Pediatr Anesth 2005; 15: 1094–7.

Address:Rolf J. Holm-KnudsenDepartment of AnaesthesiaCenter of Head and OrthopaedicsCopenhagen University HospitalHOC 4231, RigshospitaletBlegdamsvej 9DK-2100, CopenhagenDenmarke-mail: [email protected]

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Paediatric airway management: basic aspects