A 3-year-old boy presents to the emergency department with high fever, sore throat, drooling, inspiratory stridor, tachypnea, and sternal retractions. Which of the following is the most appropriate management of airway obstruction?

A 3-year-old boy presents to the emergency department with high fever, sore throat, drooling, inspiratory stridor, tachypnea, and sternal retractions. Which of the following is the most appropriate management of airway obstruction?

• A. Awake tracheal intubation in the emergency room
• B. Transfer to the OR awake tracheal intubation
• C. Transfer to the OR, inhalation induction, and tracheal intubation
• D. Transfer to the OR, IV induction, paralysis with succinylcholine, and tracheal intubation

Answer: (C)

The main idea is securing a difficult pediatric airway while preserving the child’s own breathing. In suspected epiglottitis or a severe upper airway obstruction, trying to intubate while the child is awake or after rapidly paralyzing them can precipitate complete airway collapse or laryngospasm. The safest, most controlled approach is to bring the child to the operating room and perform an inhalational induction that preserves spontaneous ventilation. Once the airway is adequately anesthetized and the patient is still breathing on their own, the trachea is then intubated. This strategy minimizes the risk of losing the airway before it is secured. Awake intubation, whether in the ED or in the OR, is not ideal in this scenario due to the child’s distress and the higher risk of agitation and laryngospasm. Using IV induction with neuromuscular blockade (paralysis) before securing the airway is avoided because paralysis can render the airway unventilated if intubation fails or if the airway is already compromised.

The main idea is securing a difficult pediatric airway while preserving the child’s own breathing. In suspected epiglottitis or a severe upper airway obstruction, trying to intubate while the child is awake or after rapidly paralyzing them can precipitate complete airway collapse or laryngospasm. The safest, most controlled approach is to bring the child to the operating room and perform an inhalational induction that preserves spontaneous ventilation. Once the airway is adequately anesthetized and the patient is still breathing on their own, the trachea is then intubated. This strategy minimizes the risk of losing the airway before it is secured.

Awake intubation, whether in the ED or in the OR, is not ideal in this scenario due to the child’s distress and the higher risk of agitation and laryngospasm. Using IV induction with neuromuscular blockade (paralysis) before securing the airway is avoided because paralysis can render the airway unventilated if intubation fails or if the airway is already compromised.