• Bogumiła Wołoszczuk-Gębicka, Lidia Zawadzka-Głos, Jerzy Lenarczyk, Bożena Dorota Sitkowska, and Iwona Rzewnicka.
• Department of Paediatric Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. bogumila.gebicka@wum.edu.pl.
• Anaesthesiol Intensive Ther. 2014 Apr 1;46(2):88-91.

AbstractWe present two cases of a "cannot ventilate, cannot intubate" scenario in children in view of the latest guidelines for the management of unexpectedly difficult paediatric airways. Case 1 was a 5-year-old boy with Treacher-Collins syndrome who suffered gastric rupture due to gastric distension with oxygen during attempts to maintain oxygenation at the induction of anaesthesia. Difficulties in maintaining this patient's airways should be attributed to functional rather than anatomical obstruction, because no such problem occurred during subsequent anaesthetic inductions; therefore muscle relaxation would be helpful in this situation. In case 2, vecuronium was used in a 10-month-old infant scheduled for elective laryngoscopy because of stride due to vocal cord paralysis. Because of congenital maxillo-facial malformation, the infant could not be intubated, and ventilation via a face mask became difficult. Facing rapid deterioration of oxygenation, neuromuscular block was reversed with the use of sugammadex. The recovery of spontaneous respiration was almost immediate, and normal motor function returned within 90 s. Functional airway obstruction due to laryngospasm, insufficient depth of anaesthesia, or opioid-induced muscle rigidity with glottic closure can occur in a healthy child, as well as in a child with difficult airways, and requires clear concepts and therapeutic algorithms. Recent paediatric guidelines for the management of unexpectedly difficult airways stress the role of muscle relaxants in overcoming functional airway obstruction. The possibility of reversing neuromuscular block produced by rocuronium or vecuronium with sugammadex to awaken the patient adds to the safety of this algorithm.

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