Airway Management - Science topic

Airway management in pediatric anesthesia presents unique challenges due to anatomical and physiological differences compared to adults. Here are some of the challenges and strategies for pediatric airway management:

Challenges:

Strategies:

By implementing these strategies and maintaining vigilance, healthcare providers can effectively manage the challenges associated with pediatric airway management and ensure safe perioperative care for pediatric patients.

The principles of airway management in paediatric anaesthesia are crucial for ensuring adequate oxygenation, ventilation, and prevention of complications during surgery. Here's an outline of the key principles and techniques, along with the use of different airway devices:

By adhering to these principles and techniques, anaesthesia providers can effectively manage the paediatric airway, maintain optimal oxygenation and ventilation, and minimize the risk of airway-related complications during surgery and anaesthesia. Close attention to patient assessment, selection of appropriate airway devices, and readiness to manage emergencies is essential for ensuring safe and successful airway management in paediatric patients.

Dear Juan March, thanks for your answer and proposals..

Semi-inflated

In any way you will be able to use a fiberoptic laryngoscope and ready for alternative intubation such as emergency tracheastomy.

It is important to note that the

failure of one device increases the possibility of failure of the next one, for example, in an obese patient with

positive predictors of difficulty for intubation, has a higher incidence of difficulty for ventilation

(including ventilation through a supraglottic device); likewise, percutaneous access to VA can be

very complicated.

Fortunately, we can exchange between these

access to the VA when one of them fails, being able to be

used interchangeably as a rescue for oxygenation

of the patient.

British Journal of Anaesthesia, 117 (S1): i20–i27 (2016) doi: 10.1093/bja/aew175

Airway management in unstable cervical spine fracture patient is always challenging. The primary reason for intubation may differ in different situations.It can be both difficult as well as dangerous due to various factors and always needs to be individualised with minimised spine movements.

Patient related factors-

Urgency of intubation- can be immediate, emergent, urgent or elective- actually dictates the decision, technique of airway management as well as drug used. The patient may be hypoxic, almost in arrest to relatively stable.

Level of injury (e.g. C1-C2 or lower cervical), Degree of instability and Severity of spinal cord compression, Anterior or posterior compression (which movement can aggravate the compression and hence to avoid), Presence of Spinal shock, Immobilisation

Presence of traumatic brain injury (increased ICP) and/ or polytrauma leading to shock or crush injury (dose and response to drugs) Facial or airway trauma, Full stomach status, Anatomical factors for difficult airway.

Other factors to be considered-

Level of experience of the person performing intubation

Equipments available for intubation (special equipments- videolaryngoscopes or flexible scopes), Drugs available for intubation, Time and place of intubation (ER/ Trauma ICU/ primary care center before transfer).

Later on, presence/absence of major neurological deficit also affects technique of airway management though such assessment may not be possible in emergent unconscious patients.

Additionally, often the issue is whether to intubate (in inadequately equipped place by inexperienced person) and then transfer to higher center is safer or the other way round. Mode of transport also needs to be addressed.

It must be appreciated that airway management is not just a technique bur a sequence of pharmacological and technical interventions right from suction and oxygenation done in least detrimental way.

Thank you all for your diverse and informative answers. Dr.Paul Baker, myself and other members of the Society for Airway Management are putting together a paper on the concept of an Airway Lead. I was wondering what the level of interest would be generated by this publication. "Testing the waters" is a great service of the Research gate community. So thank you all. I have attached an Info-Graphic for our paper on Airway Lead can you let me know what you think? Clear or unclear? Too cute or the correct tone and style?

Torsional retraction of the tongue and soft palate? I’m sure anaesthesiologists might also be able to help...

Aside from the traditional lash reflex test I will test the patient's jaw tightness before attempting an airway manipulation. Patients reach readiness for airway manipulation at different rates and with varying dosages of medications depending on, metabolic rate, cardiac function, volume status and nutritional state. So 20 seconds either way can have a big effect. If you do not have adequate hypnotic and neuromuscular junctions blockade levels at the time of airway manipulation this can cause brochospasm, laryngospasm and damage to the oropharynx.

Other valuable references, implementation-oriented:

We all know there are multiple ways of securing a difficult airway. However for the scenario presented here the additional concern is a uncorrected coagulopathy. All those who might regularly do a fiberoptic nasal intubation might be well aware of the fact that despite adequate precautions and preparation railroading the ETT over successfully inserted fiberoptic bronchoscope might cause significant nasal bleed. To me its a bad choice to think of any nasal intubation tecnique in a uncorrected coagulopathy. Yes ! oral fiberoptic guided intubation does makes sense. We must perhaps choose a technique that will result in minimum chance of bleeding. To me if the anaesthesiologist is skilled and experienced in this technique he must think of Retrograde intubation using a J tipped guide wire and passing a oral fiberoptic bronchoscope followed by ETT.This should cause minimal trauma to any soft tissue.offcourse it goes without saying you need to ensure maximum patient cooperation,good topicalisation with LA and an experienced and skilled intubator.

Flexible Fiberoptic specially awake intubation (if applicable) is the safest.

"Depth, Rate of Chest Compressions During CPR Impact Survival in Cardiac Arrest" -  Febbraio 6, 2015

DALLAS, Tex -- February 6, 2015 -- The depth of chest compressions and the rate at which they were applied make a significant impact on survival and recovery of patients, according to 2 studies published in Circulation and Critical Care Medicine.

Contrary to popular belief, the studies showed that cardiopulmonary resuscitation (CPR) compressions deeper than 5.5 cm resulted in decreased survival, possibly because of collateral damage to other internal organs.

Previously, investigations and guidelines indicated that deeper compressions were better. The American Heart Association's (AHA) 2010 CPR guidelines recommend compressing the chest at least 5 cm without providing any upper limit.

“Most people do not recognise that it takes quite a bit of thrust to compress the chest 2 inches,” said Ahamed Idris, MD, by UT Southwestern Medical Center, Dallas, Texas. “About 60 pounds [27 kg] of pressure are required to reach this depth, but in some cases a burly fireman or well-intended volunteer can go way past that amount, which can harm the patient.”

The researchers also found that the rate at which chest compression was applied was most important. Compression rates of 100 to 120 per minute were optimal for survival when other factors were considered.

“Survival depends on the quality of the CPR,” said Dr. Idris. “Both the depth of chest compressions and the rate at which they are applied can have important results for patients in the first moments of cardiac arrest.”

About half of responders are giving chest compressions too fast, with about a third above 120 compressions per minute, and 20% above 140 per minute, said Dr. Idris.

The researchers will continue to oversee innovative clinical trials to test the early delivery of interventions for serious trauma and cardiac arrest as part of a federally funded consortium aimed at advancing prehospital emergency care.

The Resuscitation Outcomes Consortium (ROC) has enrolled tens of thousands of patients to test prehospital interventions to improve outcomes in severely ill or injured patients before they are transported to a hospital.

Dear Roberto, thank you for sending on my comments. I have now met the inventor who brought samples for me to use and we did use it together yesterday. A size 4 slipped in easily into a male patient and achieved a seal pressure of 34. There was slight epiglottic down folding I guess, while using this latest version. It improved when I pulled the device out partially. I will try it on my vomiting model in the next couple of weeks. It would be good to keep in touch and to do some collaborative work together. I confess that I have been slow to respond to your kind comments with many personal demands recently. My email is donald.miller@kcl.ac.uk

If they need analgesia, they don't need CPR; if they need CPR, they don't need analgesia.

I have been doing anesthesia for 30+ years, I never believed nor practiced cricoid pressure in a single patient. I strongly support the current views that it is useless and actually might be harmful in situations like difficult intubation.

I could not find any comments related to problems in CFD analysis due to continuity limitations of the 3d reconstructed model. I think that models with C0 continuity are difficult to do anlysis with. But I need to know what are the actual problems that lie.

The trachea curves first ventrally and then dorsally and the bevel is one of the ETT- safety design items, making sure that even when the tip of the ETT lays against he tracheal wall it is not obstructed. With the bevel ventral or dorsal (i.e. anterior or posterior) this risk of tip occlusion would be potenially threatening. The ETT design has to follow safety issues before following some special placement desires (infact, most ETT's are placed without a scope or bougie).

Good question; I too am only familiar with the various country / society algorithms. I've never seen evidence that specifically addresses the value of a D.A. checklist.

Yes, well recognised and can even trigger ASB breaths in brainstem dead patients - important in apnoea testing:

There is plenty of evidence suggesting that videolaryngoscipes are more successful at managing difficult airway (when difficulty is defined by limited view at Macintosh laryngoscopy). Choosing the videolaryngoscope that you have some experience in using in normal airways is important point mentioned previously as almost all videolaryngoscopes require some adjustment to your intubation technique.

I would disagree though with ILMA (Fastrach LMA) being selected as suitable device for use in failed intubation. This device has to be used with the guidance of fibreoptic scope if it is to be effective (UK DAS guidelines). A number of surveys in the UK pointed towards limited experience with this device. Blind intubation through the ILMA has a success rate of around 80% - not enough for a failed intubation rescue device. Fibreoptic guided intubation through ILMA has much higher success rate but requires significant amount of training before proficiency is achieved.

I would argue that learning to use a videlaryngoscope is much simpler and easier than learning to intubate through ILMA with fibreoptic guidance.

Use of Airtraq and Pentax AWS in the prehospital setting is now well researched and supports the use of these portable devices that are shock and water resistant to a reasonable degree.

Iwould like to share my experience also. Due to legal liability I think the best way is to stick with guidelines, that ASA or DAS guidelines where in predicted difficulty only awake management is proposed. I usually perform adequate local anaesthesia and then I try to perform one laryngoscopic attempt using the Airtraq laryngoscope. If there is such a narrow glottis that the tube cannot pass, I revert to surgical airway. Up to now I have not failed to manage any obstruction. I usually have the choice of fibeeoptics but from experience it is time consuming and there is a possibility of totally obstructing the already narrow glottis.