International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction
Section snippets
Consensus objective
To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery.
Target population
All pregnancies with concern for neonatal airway obstruction.
Intended users
These consensus recommendations are intended to inform:
- 1.
Otolaryngologists who provide prenatal consultation for anticipated airway obstruction and perinatal airway treatment.
- 2.
Medical professionals including, but not limited to, maternal fetal medicine specialists, neonatal intensive care unit specialists, anesthesiologists, and others who collaborate in the care of these patients.
Methods
Consensus guidelines are based upon expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was used to establish recommendations on the prenatal and perinatal management of anticipated neonatal airway obstruction. An online survey was designed by two authors (MP and RS). The survey was distributed to all members of the IPOG and responses recorded. Twenty-seven responses were received from experts in eight countries. The
Disclaimer
This report has been prepared by the members of the International Pediatric Otolaryngology Group (IPOG). Consensus recommendations are based on the collective opinion of the members of the group. Any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual patient and institutional circumstances.
Recommendations and justification
- Section 1
: Etiologies of perinatal airway obstruction
Section 2: Imaging evaluation
Section 3: Adjunct evaluation
Section 4: Multidisciplinary team and decision factors
Section 5: Micrognathia management
Section 6: CHAOS management
Section 7: Head and neck mass management
Section 8: Attended delivery procedure
Section 9: Delivery on placental support procedure
Conclusion
Conditions potentially causing neonatal airway obstruction present substantial morbidity and mortality risk. Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.
Declaration of competing interest
The authors have no relevant conflicts of interest.
Acknowledgements
Drs. Richard Smith (senior author) and Michael Puricelli (first author) were the lead authors. Dr. Reza Rahbar provided primary consulting and guidance regarding the design of the consensus recommendations. All remaining authors are listed in alphabetical order. All authors have contributed to the conception and design of the work, drafting and revising the consensus recommendations for important intellectual content, final approval of the version to be published, and agreement to be
References (72)
- et al.
Ex utero intrapartum treatment (EXIT) procedures
Semin. Pediatr. Surg.
(2019) - et al.
Fetal evaluation and airway management
Clin. Perinatol.
(2018) Prenatal consultation with the pediatric otolaryngologist
Int. J. Pediatr. Otorhinolaryngol.
(2014)Infants with prenatally diagnosed anomalies: special approaches to preparation and resuscitation
Clin. Perinatol.
(2012)Clinical outcome of fetuses with sonographic diagnosis of isolated micrognathia
Obstet. Gynecol.
(2003)- et al.
Management of airway obstruction in the Pierre Robin sequence
Int. J. Pediatr. Otorhinolaryngol.
(1991) - et al.
The EXIT procedure: principles, pitfalls, and progress
Semin. Pediatr. Surg.
(2006) Predicting the severity of congenital high airway obstruction syndrome
J. Pediatr. Surg.
(2010)Syndromic micrognathia and peri-natal management with the ex-utero intra-partum treatment (EXIT) procedure
Int. J. Oral Maxillofac. Surg.
(2010)Ex utero intrapartum treatment (EXIT) in the management of cervical lymphatic malformation
J. Pediatr. Surg.
(2015)
Ex utero intrapartum treatment (EXIT) for fetal neck masses: a tertiary center experience and literature review
Int. J. Pediatr. Otorhinolaryngol.
Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses
J. Pediatr. Surg.
Airway compromise in the fetus and neonate: prenatal assessment and perinatal management
Semin. Fetal Neonatal Med.
Objective diagnosis of micrognathia in the fetus: the jaw index
Obstet. Gynecol.
The ex utero intrapartum treatment procedure: looking back at the EXIT
J. Pediatr. Surg.
Differential risk for neonatal surgical airway intervention in prenatally diagnosed neck masses
J. Pediatr. Surg.
Cervical teratomas: an analysis. Literature review and proposed classification
J. Pediatr. Surg.
Congenital high airway obstruction syndrome (CHAOS): natural history, prenatal management strategies, and outcomes at a single comprehensive fetal center
J. Pediatr. Surg.
Spectrum of intrapartum management strategies for giant fetal cervical teratoma
J. Pediatr. Surg.
Management of the critical airway when an EXIT procedure is not an option: a case report
Int. J. Pediatr. Otorhinolaryngol.
Short-term maternal outcomes that are associated with the EXIT procedure, as compared with cesarean delivery
Am. J. Obstet. Gynecol.
Maternal morbidity and reproductive outcomes related to fetal surgery
J. Pediatr. Surg.
Uterine scar rupture - prediction, prevention, diagnosis, and management
Best Pract. Res. Clin. Obstet. Gynaecol.
Long-term outcomes after fetal therapy for congenital high airway obstructive syndrome
J. Pediatr. Surg.
Congenital high airway obstruction syndrome: natural history and management
J. Pediatr. Surg.
Prenatally diagnosed neck masses: long-term outcomes and quality of life
J. Pediatr. Surg.
Seldinger-assisted videotelescopic intubation (SAVI): a common sense approach to the difficult pediatric airway
Otolaryngol. Head Neck Surg.
Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation
Int. J. Obstet. Anesth.
Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation
Int. J. Pediatr. Otorhinolaryngol.
Fetal airway management on placental support: limitations and ethical considerations in seven cases
J. Obstet. Gynaecol.
Micrognathia. Am J Obstet Gynecol
Transmission of the dysgnathia complex from mother to daughter
Am. J. Med. Genet.
Fetal micrognathia: almost always an ominous finding
Ultrasound Obstet. Gynecol.
Predictive factors for perinatal outcomes of infants diagnosed with micrognathia antenatally
Ear Nose Throat J.
Determining risk factors for early airway intervention in newborns with micrognathia
Laryngoscope
Airway management of neonates with antenatally detected head and neck anomalies
Arch. Otolaryngol. Head Neck Surg.
Cited by (17)
Perinatal airway management in neonatal goiter: A healthcare cost and utilization project (HCUP) kids’ inpatient database analysis
2023, International Journal of Pediatric OtorhinolaryngologyThe difficult neonatal airway
2023, Seminars in Fetal and Neonatal MedicineThe neonatal airway
2023, Seminars in Fetal and Neonatal MedicineEX-UTERO INTRAPARTUM TREATMENT (EXIT)
2021, Revista Medica Clinica Las CondesRisk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses
2021, International Journal of Pediatric OtorhinolaryngologyEXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects
2021, Seminars in Pediatric SurgeryCitation Excerpt :Furthermore, it is important to note that the full spectrum of the aforementioned features might not be met in all cases, and it is not required to warrant additional work-up.8 Scanning for additional malformations (present in approximately 50%) is mandatory for counseling.8 The most frequent associated genetic condition is Fraser syndrome, which is an autosomal recessive disorder characterized by tracheal or laryngeal atresia, cryptophthalmos, bilateral renal agenesis, urogenital tracts anomalies and syndactyly or polydactyly.46