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HWN Suggests

Pediatric Difficult Airway

Anticipate the Worst! 1 out of 5 is a concerning number – All pediatric patients should be considered to have a Difficult Airway until you successfully intubate them… then you can hit the “easy” button. There are no “easy airways” in the ED, regardless of age. Patients that require intubation in the ED have, be definition, stressed physiologic systems and, as such, should be considered difficult until proven otherwise.

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  Vortex Airway RESCUE Cart

The Vortex Airway Rescue Cart differs from most conventional airway carts in 3 important ways...

  A Simplified Approach to Managing the Difficult Airway in Children

Clinicians should prepare for difficult airways by training, practising, and undertaking a thorough assessment. However, even with the best assessment, you may not anticipate the difficulty, and even the most experienced clinician may struggle. Difficulties are often not related to a lack of skill or knowledge; instead, errors are more likely due to human factors and clinicians becoming cognitively overloaded. The consequences of this are impaired decision-making, task fixation, task omission, and failure to act. These can make it challenging to move forward in an algorithmic approach.

  Intubation of the critically unwell child in the emergency department

Like many things in paediatrics, there isn’t a ‘perfect’ drug or combination of drugs for anaesthesia in an emergency setting. The combination that is advocated and relied upon by critical care teams is Ketamine (1-2mg/kg) (+/- Fentanyl 1.5 microgram/kg) and Rocuronium (1mg/kg).

 To bougie or not to bougie as a first attempt intubation – and what is a bougie anyhow?!

What we colloquially refer to as a “bougie” is actually an “Eschmann endotracheal tube introducer”. So we are clear on what we are talking about here: the light blue colored, stiff but coated in a smooth plastic, “slick stick” that has a bend in it. When you advance it into the trachea, it provides some tactile feedback of a gently “clunk clunk clunk” as you glide over the cartilaginous rings of the trachea. So you know if you are in the trachea before you have chest rise, condensation in the ETT, or ET CO2.

Articles of Interest

Management of the difficult airway in the pediatric patient

Difficult airways can be anticipated and unanticipated. The latter situation is undoubtedly more stressful for medical professionals and prone to errors, as teams often need to be prepared and ready with equipment. Although unanticipated tracheal intubations have more severe complications and require more attempts, studies show that most difficult airways in children are, in fact, predictable.

Difficult to Ventilate and Oxygenate: The Pediatric Airway Overview

Critically ill pediatric patients can make physicians-in-training nervous - and that anxiety is heightened when it comes to a pediatric patient in respiratory distress. This article reviews the basics of managing the pediatric airway, which has key differences from the adult airway.

Management of Difficult Airway Scenarios

Cannot intubate and cannot ventilate (CICV) in a paralysed anaesthetised child aged 1 to 8 years.

Management of the Difficult Airway

List of references...

Management of the Unexpected Difficult Airway in Neonatal Resuscitation

Skilled airway management is required even for anatomically normal neonatal airways. In expected and unexpected difficult intubation in children, patients <10 kg are more prone to complications than larger patients. This is because of rapid desaturation due to a lower functional residual capacity and higher oxygen consumption, as well as lower success rates of advanced airway rescue techniques.

The Difficult Paediatric Airway

As in adults, difficult airways in children may be anticipated or unanticipated. Some form of difficult airway, either difficult bag-mask ventilation, or difficult intubation, may be anticipated in the following congenital or acquired disorders...

The difficult pediatric airway for emergency medicine

If BMV cannot maintain oxygenation and the trachea cannot be intubated ("failed airway"), the clinician should place a supraglottic device if not contraindicated (eg, upper airway obstruction, trauma, or midface fractures).

The Management of difficult intubation in children

The LMA now has a central role in the management of the difficult pediatric airway. Although first developed as an airway which could free up the hands of the anesthetist it has proven to be much more. Firstly, it can be of use as an alternative to endotracheal intubation for short cases. It can be used as a rescue airway and can be used during a failed intubation scenario to maintain oxygenation and anesthesia. It can also be used most effectively as a conduit to facilitate fiberoptic intubation

The Pediatric Difficult Airway Toolkit

Overall, this case suggests pediatric/neonatal adjuncts are potentially underutilized and deserve further study.

Resources

Pediatric Difficult Intubation (PeDI) Registry

Pediatric Difficult Intubation (PeDI) Registry group is a multicenter organization dedicated to assessing, understanding and improving the outcomes of children with Difficult Direct Laryngoscopy (DDL) to facilitate benchmarking, quality improvement and research. The objectives of the group are (1) to provide site specific and aggregate data back to sites on DDL events and (2) to augment local quality improvement efforts and (3) to facilitate research studies related to DDL.

The Difficult Airway Course

The definitive course for airway management education.

The Vortex Approach

While technical competence and adequate planning are crucial to effective airway management, it is well recognised that even well prepared airway clinicians can sometimes fail to perform basic interventions under stress. Completion of a 'best effort' at any of the three upper airway lifelines without being able to restore alveolar oxygen delivery mandates spiral movement inward towards the next lifeline. The circular arrangement of the three lifelines on the tool means that airway management can be initiated using any lifeline and proceed to the remaining ones in whatever sequence is judged most appropriate in the clinical circumstances.

Open Anesthesia

Dr. John Fiadjoe and OpenAnesthesia Editor Dr. Aditee Ambardekar discuss the topic of pediatric difficult airway.