A two year child presents with fever, stridor and a harsh cough.
His condition deteriorates and he requires intubation.Outline how you would do this.
Call for help
This should be in context-
a) if the child becomes hypoxic/has a respiratory arrest etc-proceed with attempt bag mask
ventilation 100% oxygen immediately - attempt intubation.
b) If there is time-aim to have the person with the best paediatric airway management expertise
Optimise medical management
a) High flow oxygen
b) if child hypoxic -can discuss avoiding distressing the child by holding mask away from face and
with child on parents lap (unless really sick)
c) IV steroids-adequate dose 00.6mglkg dexamethasone
d) NEB adrenaline 5mg (repeated doses)
e) Oxygen/Helium mixture if tolerates
Adequate discussion of preparationfor intubation
a) range of ETTs (size 4.0, 4.5. 5.0, 5.5)
b) two laryngoscopes with range of blade sizes-straight/curved
c) small diam "bougie"
d) cannula for percutaneous needle cricothyroidotomy + method for oxygen delivery
Intubation: One of 2 approaches
(1) Inhalational induction of anaesthesia with maintenance of spontaneous ventilation until adequate
depth of anaesthesia achieved to allow intubation (or to assess ability to ventilate-then proceed to
Or (2) IV induction-with paralysis
There must be some discussion regarding risks of either technique. Mere mention of IV approach will
not be enough to gain marks • There must be some discussion regarding risks of either technique
However, if not trained in inhalational anaesthetic techniques-reasonable to proceed with IV
induction of anaesthesia +muscle paralysis -with risk of being unable to ventilate
Alternate strategies if unable to intubate
Ventilate with LMA/face mask until help arrives
Rarely need to proceed to needle cricothyroidotomy
- Call for senior anaesthetic help. The person with the best paediatric airway management expertise should intubate the child.
- Explore alternatives to intubation. In the case of the child with an airway obstruction or stridor, this may consist of the following options:
- Adrenaline nebs
- Steroids (if the aetiology calls for it)
- Optimise pre-intubation management: This consists of adequate pre-oxygenation. It may be necessary for the child to be pre-oxygenated in the parents' lap
- Sit up 90°
- CPAP may help by reducing the dynamic component of stridor
- Atropine can be given (20 µg/kg) to dry secretions
- Explore airway control options:
- Inhalational induction is usually Plan A. The whole point is to maintain spontaneous respiration throughout the process, using gas to attain a level of anaesthesia which permits intubation. Best to induce them in a sitting position. Be prepared to wait- gas induction is slow in airway obstruction. When the patient is ready, they are rapidly made supine and intubated by laryngoscopy.
- IV induction with paralysis is usually Plan B.
- If unable to intubate, proceed to LMA. If LMA ventilation is successful, one can prepare for a repeat attempt at intubation, with a variety of difficult intubation equipment available, senior staff on standby, and with manoeuvres to improve visibility (eg. improved head position, BURP, videolaryngoscopy)
- If unable to ventilate with LMA, proceed to needle cricothyroidotomy. This is difficult in children. Skilled proceduralists only seem to have a 60% success rate, and puncture the posterior wall of the trachea about 47% of the time.
- If jet oxygenation can be accomplished, one has some time to set up for a Seldinger dilation and insertion of a pediatric ETT, or for a retrograde intubation.
- If jet ventilation cannot be accomplished, one must assess the difficulty of anterior neck anatomy.
- if the anatomy is easy, one can proceed to a scalpel-bougie tecnique (where one makes an incision in the cricothyroid membrane and railroads the tube in over a hollow jet ventilation bougie)
- if the anatomy is difficult, one must perform a scalpel-needle cricothyroidotomy (where the cricothyroid membrane is identified by palpation through an incision, so that the jet cannula can be inserted)
- Optimise team communication: Ensure all team personnel are aware of the algorithm and understand the steps.
- Optimise the first attempt:
- Skilled staff present and briefed about Plan A and Plan B
- Optimise subsequent attempts:
- Checked equipment with backup models
- Senior anaesthetist and ENT surgeon available
- Ensure availability of ultra-fine (~ 2mm) intubating bronchoscope for paediatric work
Heard, A. M. B., R. J. Green, and P. Eakins. "The formulation and introduction of a ‘can't intubate, can't ventilate’algorithm into clinical practice." Anaesthesia64.6 (2009): 601-608.
Stacey, Jonathan, et al. "The ‘Can't Intubate Can't Oxygenate’scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy." Pediatric Anesthesia 22.12 (2012): 1155-1158.
Weathers E., "The Anatomy of the Pediatric Airway" 2010 -RC EDUCATIONAL CONSULTING SERVICES, INC.
Santillanes, Genevieve, and Marianne Gausche-Hill. "Pediatric airway management." Emergency medicine clinics of North America 26.4 (2008): 961-975.
HOLM‐KNUDSEN, R. J., and L. S. Rasmussen. "Paediatric airway management: basic aspects." Acta Anaesthesiologica Scandinavica 53.1 (2009): 1-9.
Cardwell, Mary, and Robert WM Walker. "Management of the difficult paediatric airway." BJA CEPD Reviews 3.6 (2003): 167-170.