3,688
edits
Paediatric difficult airway management: Difference between revisions
Jump to navigation
Jump to search
Paediatric difficult airway management (view source)
Revision as of 16:06, 12 February 2023
, 1 year agono edit summary
No edit summary |
No edit summary |
||
| Line 214: | Line 214: | ||
:• Increase depth of anaesthesia | :• Increase depth of anaesthesia | ||
:• Ventilate using a two-person technique (one holding the mask with two hands, the other ventilating by squeezing the bag) | :• Ventilate using a two-person technique (one holding the mask with two hands, the other ventilating by squeezing the bag) | ||
:• Pass a nasogastric tube to deflate the stomach. | |||
[[File:Difficult_mask_ventilation_algorithm.jpg|800px|center|Figure 1: Difficult mask ventilation algorithm. Reproduced with kind permission of Association of Paediatric Anaesthetists]] | |||
If mask ventilation is impossible despite all the above measures or the | |||
child’s oxygen saturation begins to fall: | |||
:EITHER insert an LMA (if available), | |||
:OR deepen anaesthesia, attempt to visualise the vocal cords and | |||
intubate the trachea. | |||
There is no randomised controlled trial to assess which is the best | |||
response, but insertion of an LMA is recommended first, and then | |||
intubation (Figure 1). | |||
If oxygenation and ventilation is satisfactory through the LMA or | |||
tracheal tube then it is safe to proceed with surgery. | |||
If in doubt, wake the child up. | |||
===2. Unexpected difficult tracheal intubation=== | |||
A simple algorithm for the management of unexpected difficult | |||
tracheal intubation is given in Figure 2: Difficult tracheal intubation | |||
algorithm. http://www.apagbi.org.uk/sites/default/files/images/APA2- | |||
UnantDiffTracInt-FINAL.pdf | |||
The key point is, if tracheal intubation fails, DO NOT simply repeat | |||
what has just failed. Multiple attempts at intubation may traumatise | |||
the airway and will cause airway oedema, which may make the child | |||
impossible to intubate. Intubation attempts must be limited to a | |||
maximum of three or four (Figure 2). | |||
If the first intubation attempt fails, it is essential to make changes | |||
that improve the chance of successful intubation. These may include: | |||
:• Change of personnel (a more senior anaesthetist); | |||
:• Change of position | |||
:• Change of equipment. | |||
Visualisation of the larynx and successful tracheal intubation are | |||
improved by: | |||
:• Proper positioning of the child, | |||
:• External laryngeal manipulation | |||
:• Adequate depth of anaesthesia and adequate muscle paralysis (if | |||
this has been used). | |||
Simple aids such as a bougie or stylet may make intubation | |||
straightforward even when the view of the larynx is poor. An alternate | |||
laryngoscope may also be used if available and if the operator is familiar | |||
with its use. | |||
Straight bladed laryngoscopes are traditionally used in children under | |||
one year old, but may be useful in older children, or in patients | |||
with relative macroglossia. They can be used with a paraglossal or | |||
retromolar technique. McCoy levering laryngoscopes are also available | |||
for paediatric use, based on a Seward blade (sizes 1 and 2) and may | |||
improve the view of the larynx, particularly if the view is obstructed | |||
by a large epiglottis. | |||
In addition to straight bladed and McCoy laryngoscopes, new alternate | |||
laryngoscopes have been developed recently (see table 1). High quality | |||
evidence supporting efficacy is largely absent in the life-threatening | |||
scenario of unexpected failed intubation. Firm recommendations | |||
cannot be made so many algorithms suggest alternate laryngoscopes/ | |||
techniques ‘should be considered’. | |||
== REFERENCES == | == REFERENCES == | ||