A two year old child presents with fever, stridor and a harsh cough. His condition deteriorates and he requires intubation. Outline how you would do this.

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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 (` 0.6mg/kg dexamethasone d) NEB adrenaline 5mg (repeated doses)
e) Oxygen/Helium mixture if tolerates

Adequate discussion of preparation for intubation 
a) range of ETT’s (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

Ohs Manual has a whole chapter on pediatric airway managemnt, and the child with stridor receives some attention (page 1099). I will paraphrase their suggestion regarding the management of such a problem.

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 sucessful, one can prepare for a repeat attempt at intubation, with a variety of difficult intubation equipment avalable, 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. Skileld 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 retrgrade 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 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

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.