Point - Counterpoint
Commentary
Where to begin in discussing this very vexing and frequently occurring problem? Specifically, what airway management is best for a child, who has a viral URI, presenting for an elective surgical procedure? Whenever I am uncertain about an area in medicine, I look to definitions as a starting point. In my 15th edition of Nelson's Textbook of Pediatrics, chapter 327.1, which is all of one page in length in this 2000 page text, is titled Acute Nasopharyngitis, with the subheading "the common cold". Clinical manifestations of
"the common cold" for infants listed include in the textbook include: sneezing, nasal discharge leading to obstruction severe enough to interfere with feeding and only rarely, fever. In older children, fever is often seen early in the course of a cold not throughout. In addition, there is often nasal discharge, sneezing and non-productive cough. The differential diagnoses of the common cold mentioned include: allergic rhinitis and early measles or mumps, to which I would add crying, sniffling of an anxious child in the pre-anesthetic holding area.
The preceding remarks show how difficult it is to make a certain diagnosis of "cold" or URI during a short visit in the pre-anesthetic holding area. This difficulty is compounded by the trouble in determining the clinical significance of any problem encountered in the anesthetic care of a child with that diagnosis. Dr. Tait cites and has himself contributed compelling evidence that intubation in children with URI's can lead to more respiratory problems in the perioperative period. He reviews evidence that the use of other airway management techniques, facemask and LMA, leads to fewer airway complications.
Given the prominence of Dr. Tait's work in this area, I thought it would be of interest to have two different individuals take the view that intubation of children with URI's might be advantageous. Dr. Krupp points out the rather large number of surgical procedures and situations when intubation is not only a choice but probably the best or even only choice for airway management and correctly asserts that, with care and attention to detail, the anesthetic may proceed without complication. I find the remarks of Dr. Cross very interesting. While not denying the current literature, he does note the possible disadvantages airway maintenance with a facemask during anesthesia. The presence of a URI certainly does not make mask anesthesia easier. He also correctly comments that there may be complete loss of the airway at any time during the conduct of the anesthetic if that airway is not secured. As Dr. Krupp did, Dr. Cross also mentions cases where the airway must be secured as well as those where on balance, even in the presence of a URI, intubation may be safer than not doing so.
This discussion reminds me of those we had during my time as a fellow in medical ethics recently. The answer to almost all of the problems we analyzed seemed to always be "It depends". While I must agree with Dr. Tait's opinion and review of current literature on this topic that in general, intubation of children with URI's will lead to an increased incidence of airway and/or respiratory complications, the common thread I see in the remarks of both Dr. Krupp and Dr. Cross also has merit. That thread, not specifically articulated but there nevertheless, is the importance of a careful, thoughtful evaluation of each situation and the formation and carrying out of a plan by someone expert in the anesthetic care of children.
Thomas J. Mancuso, MD, FAAP
Children's Hospital, Boston
#include ./footer_include.iphtml