Managing the Child with a Compromised Airway
In this step, Dr Stephanie Bew, Consultant Paediatric Anaesthetist at Leeds General Infirmary, outlines how to manage the very frightening situation of a child with an obstructed or compromised airway.
Most paediatric airways are not difficult, and most difficult airways can be identified easily. In the UK, specialised paediatric surgery and paediatric intensive care is centralised in a small number of tertiary hospitals, but in an emergency children can present to any hospital. In non-specialist hospitals, anaesthetists may get few opportunities for routine paediatric airway management and skill maintenance. This causes understandable anxiety when they are called to manage acute airway problems or complex children requiring urgent intubation.
We have already explored the the 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society several times in the course and return to it again here. In the report it was noted:
Airway management in children is generally straightforward, but can occasionally be an extraordinary challenge
Thirteen paediatric cases were reported including 3 deaths. Recommendations included:
- Use full monitoring including capnography.
- Advanced airway equipment should be rapidly available in theatres, emergency departments and ITU’s.
- Get senior help and involve ENT early.
- Transfers within and between hospitals require good planning, full monitoring, and equipment to deal with loss of the airway in transit.
- It’s important to inspect the airway and clear blood prior to extubation.
Other key messages included:
- Unpredicted difficult intubation was often managed by repeated attempts using the same technique leading to airway trauma.
- Cardiovascular complications of airway events. Hypoxia can rapidly progress to bradycardia and cardiac arrest. Practitioners must be competent at advanced life support.
Paediatric difficult intubation is rare, but respiratory adverse events are common. Results from the APRICOT study highlighted risk factors for airway events as young age, airway hypersensitivity and higher ASA . The PeDi registry data indicate that difficult airway complications are more common in children under the age of 1 or 10kg, and increase with the number of intubation attempts .
The Compromised Airway
A child with a compromised airway makes everyone very anxious. How should we approach the situation?
- Does the child have a syndrome associated with difficulty or is this a previously well child with an acute problem- infection, allergy, injury, burns or foreign body.
- Was the child intubated as a neonate - possible subglottic stenosis.
- Is the situation stable or deteriorating? Does anything make it worse or better, what is the response to steroids or nebulised adrenaline.
- ‘Adult’ tests are not helpful in children, but look for difficult anatomy, particularly the mandible. Check mouth opening, tongue size, neck mobility, nasal obstruction. Look at the child’s position, are they drooling?
- Listen for sounds of obstruction, stridor or snoring, for cough suggesting croup or tracheomalacia or voice change suggesting laryngeal foreign body or papilloma
- Listen to the lung fields for air entry and wheeze
- Look for signs of increased effort- tracheal tug, sternal recession, nasal flare, grunting and high respiratory rate.
- Is the child on oxygen? What is the SpO2?
- Chest X-ray to check for foreign body in oesophagus or airway, chest pathology
- Vascular access. Obtained already? Does it look difficult. Do you need iv or intraosseous (IO) access or plan a gas induction?
Preparation and Planning
Think about all the the following: parents, team, equipment, checklists, cognitive aids, team brief. Remember you are part of a team alongside emergency department doctors, paediatricians and nurses, with skills in iv and IO access, drugs and airway management. Parents will be present: they will be anxious, but with help can reassure or distract their child during induction.
Traditionally a compromised paediatric airway was managed with gas induction using 100% O2, maintenance of spontaneous respiration, and laryngoscopy under deep inhalational anaesthesia. Patience and experience are needed to attain sufficient depth of anaesthesia for good intubating conditions and to avoid laryngospasm. Now, after a gas induction, many paediatric anaesthetists would give propofol to deepen, and paralyse to make mask ventilation easier and optimise intubating conditions. If direct laryngoscopy is difficult, a range of videolaryngoscopes are available for children.
Maintenance of oxygenation, avoidance of multiple attempts at laryngoscopy and the use of an SAD for rescue are key.
The Difficult Airway Society published the Paediatric Difficult Airway Guidelines for children ages 1-8 in 2012 . There are no UK nationally recognised difficult airway guidelines for children <1 year or >8 years. The guidelines are teaching and learning tools, and not designed to be used as prompts during an airway crisis. Like the adult guidelines they emphasise maintaining oxygenation, getting help and limiting the number of intubation attempts. As we have seen in Week 2, the latest adult guidelines have been simplified with plans A-D, and an emphasis on human factors with instructions to ‘stop and think’ and declaration of failure. For emergency FONA paediatric guidelines recommend cannula cricothyroidotomy  rather than the scalpel cricothyroidotomy recommended in adults.
TOP AIRWAY TIPS
- LESS TIME Preoxygenation is often not possible and infant physiology lead to rapid desaturation. There is less time for decision making or intubation attempts.
- ASSESSMENT As well as airway assessment, check whether vascular access is difficult. Is there abdominal distension or respiratory disease which will make desaturation much quicker.
- PEEP Increases airway diameter, acts as a dynamic splint and improves oxygenation
- GASTRIC DISTENSION Mask ventilation using too much pressure or PEEP causes gastric distension and makes oxygenation extremely difficult. Gas goes in more easily after an attempt at laryngoscopy as this also opens the oesophageal inlet.
- DEFLATE THE STOMACH Pass a nasogastric tube or suction catheter through nose or mouth to release the gas. Gentle pressure will empty the stomach.
- BIG TONSILS and ADENOIDS Can cause complete airway obstruction. This is usually easily overcome with a jaw thrust keeping the mouth open or using a Guedel airway once anaesthesia is deep enough.
- AVOID MULTIPLE REPEAT ATTEMPTS AT LARYNGOSCOPY If you can’t intubate with the child in optimal position, using simple adjuncts such as a bougie, you need a change of plan. Multiple repeat attempts will cause trauma, bleeding and oedema and may in the end make mask ventilation impossible.
- LARYNGOSPASM is more common in children, and usually managed easily with 100%O2, PEEP and deepening anaesthesia with propofol. If this fails and the child becomes hypoxic and bradycardic give suxamethonium. If you don’t have vascular access, give 4mg/kg into the deltoid muscle.
- NASAL OXYGEN Low flow nasal O2 can help maintain oxygenation during difficult intubation.
- GET HELP EARLY This could be senior help or ENT, but if you do a gas induction have someone ready to site an iv or IO and give drugs as soon as the child is asleep.
- CHECKLISTS AND TEAM BRIEF particularly for emergencies, anticipated difficulty and unfamiliar teams.
In 2019, The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) has launched PaEdiatric Airway Registry (PEAR) UK, a registry to enter and track all cases of paediatric difficult airway management. This database will be useful to inform practice, training and education in paediatric anaesthetics. If you and based in the UK and your hospital hasn’t registered yet, you may want to consider joining.
We have explored the paediatric airway in great detail, so now move onto the next step where we will be looking at airways in obstetrics.
Engelhardt T, Virag K, Veyckemans F, Habre W, for the APRICOT Group of the European Society of Anaesthesiology Clinical Trial Network. Airway management in paediatric anaesthesia in Europe - Insights from APRICOT (Anaesthesia Practice in Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. British Journal of Anaesthesia 121 (1):66-75 (2018)
Fiadjoe JE, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan Jr FX, Litman RS, Kovatsis PG. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis Lancet Respir Med. 2016; 4:37-48