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.

[Click here to toggle visibility of the answers]

College Answer

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 
-intubate child


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 
e) suction


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 
paralyse child) 
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

Discussion

In brief:

  • 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:
    • Heliox 
    • 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:
    • Videolaryngoscopy
    • 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

References

References

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.