Part A: Fundamentals

The Resuscitation of the Newborn With a Difficult Airway

INTRODUCTION

Successful resuscitation of the newborn nearly always begins with the establishment of a patent airway through which gas exchange will occur. However, the neonatal airway may be compromised by a number of developmental anomalies that make resuscitation challenging. Some of these anomalies are relatively benign and respond to simple maneuvers to achieve an airway. On the other end of the spectrum are other anomalies that may be lethal despite prenatal diagnosis and delivery at a center with advanced airway management capability. In either case, delivery room management will be influenced by the severity of the anomaly and the resulting degree of airway obstruction. Appropriate interventions in the delivery room may range from the placement of an ancillary device to maintain patency of the airway to the coordinated, multidisciplinary surgical intervention while the infant continues to be supported by the placental circulation. This chapter reviews the differential diagnosis of newborn airway obstruction and describes the overall approach to delivery room management of airway anomalies that range from mild to severe.

DIFFERENTIAL DIAGNOSIS

Obstruction of the neonatal airway may occur at many different levels. Choanal atresia is an upper airway anomaly that may cause respiratory distress immediately after birth or on initiation of early feeding attempts.¹ Choanal atresia most often is caused by bony obstruction and may affect either 1 or both sides of the nasal passages.² Choanal atresia may be isolated or a component of CHARGE association (coloboma, heart defect, atresia choanae [also known as choanal atresia], retarded growth and development, genital abnormality, and ear abnormality).³ There are other, rarer anatomic obstructive processes at the level of the nose in the neonate, ranging from the solid (glioma, rhabdomyosarcoma, and other tumors) to the cystic (dermoid and epidermoid cysts and meningoencephaloceles).

The development of the jaw and tongue may also influence initial airway management during resuscitation. Micrognathia may be seen as an associated finding with other disorders, including trisomies 13 and 18 and Treacher Collins syndrome. Macroglossia most commonly presents as part of a constellation of developmental anomalies, as would be the case in Beckwith-Wiedemann syndrome, trisomy 21, and congenital hypothyroidism. However, macroglossia also may represent underlying pathology in the tongue itself (tumor or vascular malformation) or underdevelopment of the mandible or maxillae.⁴ The combination of micrognathia, cleft palate, and upper airway obstruction defines the Pierre Robin sequence.

The newborn may present with bilateral congenital paralysis of the vocal cords. Although this typically does not result in true obstruction of the airway, the neonate may cough recurrently and develop respiratory difficulties with feedings. In congenital vocal cord paralysis, the cords are left in the open position, leaving the neonate potentially unable to protect the airway.⁵ Although not a usual cause of airway obstruction, appropriate airway evaluations should be performed. Likewise, tracheoesophageal fistula...