Paediatric Equipment Is Not Just Smaller

In addition to the usual equipment required for safe inter-hospital patient transfer, paediatric intensive care transportation has a number of specific equipment considerations…

Airway Equipment

• Paediatric patients require appropriately sized airway devices and laryngoscopes, and an appropriate airway rescue plan. Take a look at these difficult intubation guidelines for more.

• Oropharyngeal airways (OPAs) should be available, as should nasopharyngeal airways (NPAs).

If dedicated paediatric NPAs are not available, an uncuffed ETT can be fashioned into an NPA by cutting the proximal end lengthwise into three strips, which can be taped to the cheeks and forehead.

• Paediatric laryngoscope blades differ in shape as well as size. Children below 1-2 years of age have an immature hypoepiglottic ligament, meaning the epiglottis cannot reliably be manipulated with a laryngoscope blade in the vallecula. Straight blades, designed to manoeuvre the epiglottis directly, overcome this problem.

The Robertshaw blade is wider, designed to manoeuvre the relatively voluminous tongue of the toddler.

• High-volume low-pressure cuffs have allowed cuffed endotracheal tubes (ETTs) to become commonplace in paediatric critical care, particularly for internal diameters above 3.5 (below which, challenges of airway resistance and secretion clearance makes larger uncuffed tubes more attractive).

Airway Transfer Trouble

• Children have increased airway secretions compared to adults, particularly in respiratory illness, and challenging ventilation – or even obstruction – with thick secretions is a serious risk.
• Easily accessible appropriately-sized suction catheters (twice the internal diameter of the ETT) and passive airway humidification with a heat/moisture exchange filter (HME-F) should be routine.
• Continuous waveform capnography is ubiquitous, but the dead space leads to lively discussion of the relative risk of its use in premature babies – increasing miniaturisation of devices is making continuous capnography available to patients of all sizes.
• Anecdotally, smaller capnography devices are more susceptible to blockage by condensed water – potentially even within the duration of a short journey – so spares should be readily available.

Respiratory Equipment

• Paediatric critical care patients may benefit from non-invasive respiratory support and are more significantly affected by airway equipment dead space and resistance. Mask CPAP or BIPAP uses oxygen more quickly than invasive ventilation, but is efficient compared to high flow nasal cannula support.

Offering high flow support for transfers requires consideration of patient size, travel times, and vehicle oxygen supplies. Despite these challenges, some services routinely take small children on 2-3 hour journeys on high flow nasal cannulae.

• Patients may also be dependent on advanced respiratory support equipment such as high frequency oscillation ventilation (HFOV) or inhaled nitric oxide (iNO).
• Not all transfer ventilators are suitable for all paediatric patients. Flow sensors can be less accurate at smaller tidal volumes, or in the context of leak around uncuffed ET tubes, leading to challenges when using volume-control ventilation.

Smaller patients may not be able to generate adequate flows to trigger ventilators.

Cardiovascular Equipment

• Peripheral administration of adrenaline and/or noradrenaline is an established option when central or intraosseous access is not available.

Transfer Considerations

• Ambulance services have a selection of child-sized restraints. Specially designed cots for babies may be strapped to ambulance stretchers or be integrated with a neonatal transfer stretcher.
• Heat, sound, and light protection may be appropriate for the cold-weather early morning helicopter transfer.

Specialist Considerations

• Some children will require life-saving medication that may not be widely available outside of specialised paediatric hospital services. Paediatric transport teams may be the first opportunity for a child in a remote location to receive these medications.
• Special clinical scenarios such as meconium aspiration with persistent pulmonary hypertension or congenital cardiac disease may require transfer on inhaled nitric oxide and/or on HFOV. Some neonatal transport ventilators can provide HFOV by simply changing ventilation mode, but transfer on ECMO (see later this week!) may be required for older children with profound respiratory failure.

Significant nitric oxide leaks in enclosed aircraft may pose a risk to staff, and plans to increase cabin air exchange are essential.

Spare A Thought For Spares

Much of the equipment required for safe paediatric inter-hospital transfer is not widely available in non-paediatric hospitals

• Teams should make plans for spare equipment in case of clinical challenges or for back-to-back transfers without the chance for a team to re-stock. Additional support vehicles may even be needed for mid-transfer resupply.