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Key Points

  1. A child's airway is shorter and smaller in caliber than the adult's, the larynx is placed more anterior, and the structures are more collapsible. Prior to ages 8 to 10 years, the smallest portion of the airway is the subglottic trachea.

  2. Stridor merits immediate investigation and is nearly always an indication for airway endoscopy.

  3. The principal advantage of rigid over flexible bronchoscopy involves better control of the airway, but also allows access to instruments, removal of foreign bodies, or more effective suctioning capability.

  4. Rigid and flexible bronchoscopy are complementary techniques used in various circumstances to assess airway anatomy and function, in some cases concurrently.

  5. In the rare urgent case when establishment of an airway is critical and endotracheal intubation fails, the treatment of choice in children is needle access of the trachea with a large-bore angiocath.

  6. Retention sutures are placed parallel to the proposed site for a pediatric tracheotomy incision in mid-trachea. These can provide exposure of the trachea and allow replacement in the case of accidental tracheal dislodgement in the early postoperative period.

  7. There are various and numerous challenging issues for the parents after the patient is discharged home with a new tracheostomy. These may include skin and stoma care, suctioning, humidification and routine changes of the tracheostomy ties and the tracheostomy tube itself, and education for emergent situations.

Airway Endoscopy and Pathology

History of Airway Endoscopy

Curiosity regarding the mysteries of respiratory function and the need to remove airway foreign bodies have long evoked an interest in airway inspection. Early writings describe Hippocrates' recommendation that a tube be inserted into the upper airway to allow a suffocating patient to breathe. However, it was not until 1807 that the first device for showing the inner cavities of the upper airway was demonstrated by Phillip Bozzini. This primitive instrument, called a Lichtleiter (light conductor), consisted of a candle and a series of mirrors contained within a tin and leather housing. A crude laryngoscopic device introduced by Benjamin Babington in 1829 comprised a set of polished mirrors that could reflect sunlight and allowed a view of the upper larynx. In the 1850s, another instrument designed to allow visualization of vocal cord and laryngeal function was constructed from connected mirrors and demonstrated before the Royal Society by a London voice teacher. The term endoscopy was coined by Antonin Jean Desormeaux, a French neurologist who produced a similar instrument in 1853. His device used a lens and an attached light source fueled by an alcohol–turpentine mixture.

Despite the demonstration of such devices, their insufficiencies in directing illumination into the airway prevented their use in medical practice. With Edison's invention of the light bulb in 1878, this major obstacle was overcome. In the 1890s, Gustav Killian developed the first electric headlight, and in 1897, he also became the first practitioner to remove a foreign body from the distal ...

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