Numerous airway anomalies may be present at birth or develop over the first several months of life. While they rarely of themselves lead to the need for emergent airway control, their presence will complicate management of other emergencies requiring intubation.
Choanal atresia is the most common congenital anomaly of the nose. It may be unilateral or bilateral. Infants with this condition may not have difficulty breathing at birth if they can breathe orally, but they often present several months after birth when there is a concurrent problem, such as an upper respiratory infection. Maintaining an oral or tracheal airway overcomes the obstruction. Emergency department treatment is placement of oral airway, tube feedings, and admission for surgical repair.
Cystic hygroma is a benign congenital tumor of lymphatic origin. About 60 percent appear within the first year of life, and 80 to 90 percent occur before the second year. Cystic hygroma usually occurs in the neck or tongue but may also be found in the mediastinum. Progressive growth can lead to compromise of the structures of the pharynx and trachea, leading to airway obstruction and impairing or preventing laryngoscopy. The treatment is surgical resection. 2
There are five types of tracheoesophageal fistulas, the most common defect consisting of a blind upper esophageal pouch and a fistula between the lower esophagus and the trachea. The diagnosis is usually made soon after birth when an infant becomes cyanotic and starts coughing after feeding or when a catheter cannot be passed into the stomach. Although most patients present soon after birth, a few with tracheoesophageal fistula with esophageal atresia present some time after discharge with pneumonia, and cyanosis with feeding. Placement of the endotracheal tube in patients with tracheoesophageal fistula is crucial to avoid gastric insufflation and resultant aspiration. The tube should be above the carina but below the fistula. This is often achieved by intubation of the right mainstem bronchus, then pulling back until breath sounds are heard bilaterally.
The common congenital syndrome of trisomy 21 (Down syndrome) may present significant difficulties in airway management. Characteristic of these patients are a short neck, small mouth, narrow nasopharynx, and large tongue; moreover, approximately 20 percent have asymptomatic dislocation of the atlas on the axis. 3 All of the potential difficulties must be considered prior to initiating intubation. Many congenital syndromes include airway abnormalities ( IableJ.1-1). In controlled settings, management is preceded by careful evaluation and planning. Unfortunately, in the emergency department, this is rarely possible, and thus the approach to airway management must be mastered in all facets by those whose practice, even infrequently, involves pediatrics.
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Once your pregnancy is over and done with, your baby is happily in your arms, and youre headed back home from the hospital, youll begin to realize that things have only just begun. Over the next few days, weeks, and months, youre going to increasingly notice that your entire life has changed in more ways than you could ever imagine.