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Paediatric difficult airway management: Difference between revisions
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Paediatric difficult airway management (view source)
Revision as of 17:02, 12 February 2023
, 1 year ago→THE EXPECTED DIFFICULT AIRWAY
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If the preoperative airway assessment alerts the anaesthetist to expected | If the preoperative airway assessment alerts the anaesthetist to expected | ||
difficulties in airway management then there are three key questions: | difficulties in airway management then there are three key questions: | ||
1. Does the anaesthetist have the necessary paediatric airway | :1. Does the anaesthetist have the necessary paediatric airway | ||
experience? | experience? | ||
2. Does the hospital have the necessary paediatric equipment? | :2. Does the hospital have the necessary paediatric equipment? | ||
3. Does the relative benefit of the planned surgery outweigh the | :3. Does the relative benefit of the planned surgery outweigh the | ||
possible risks of anaesthesia? | possible risks of anaesthesia? | ||
If there is any doubt, full discussion should take place with the parents | If there is any doubt, full discussion should take place with the parents | ||
(or carers), child, surgeons and anaesthetists. It may be appropriate | (or carers), child, surgeons and anaesthetists. It may be appropriate | ||
for the child to be referred to specialist hospital or wait for a more | for the child to be referred to specialist hospital or wait for a more | ||
experienced paediatric anaesthetist to attend. | experienced paediatric anaesthetist to attend. | ||
The anaesthesia plan must be carefully considered, including what to | The anaesthesia plan must be carefully considered, including what to | ||
do if tracheal intubation is unsuccessful; will the child be woken up, | do if tracheal intubation is unsuccessful; will the child be woken up, | ||
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and nursing staff. Difficult airway equipment must be checked and | and nursing staff. Difficult airway equipment must be checked and | ||
prepared. | prepared. | ||
The primary plan for management of the expected difficult paediatric | The primary plan for management of the expected difficult paediatric | ||
airway will likely be one of the following: | airway will likely be one of the following: | ||
1. Laryngoscopy anticipated to be difficult but may be possible: | :1. Laryngoscopy anticipated to be difficult but may be possible: | ||
Attempt laryngoscopy and intubation. If fails, consider | Attempt laryngoscopy and intubation. If fails, consider | ||
repositioning and try alternate laryngoscopes if available, or insert | repositioning and try alternate laryngoscopes if available, or insert | ||
LMA and perform fibreoptic intubation (FOI) via LMA. | LMA and perform fibreoptic intubation (FOI) via LMA. | ||
2. Laryngoscopy predicted to be impossible: Perform nasal FOI or | :2. Laryngoscopy predicted to be impossible: Perform nasal FOI or | ||
insert LMA and perform FOI via LMA. | insert LMA and perform FOI via LMA. | ||
3. Laryngoscopy and LMA insertion known to be impossible: | :3. Laryngoscopy and LMA insertion known to be impossible: | ||
perform nasal FOI. | perform nasal FOI. | ||
4. Laryngoscopy, LMA insertion and nasal FOI not available | :4. Laryngoscopy, LMA insertion and nasal FOI not available | ||
or known to be impossible: perform tracheostomy either using | or known to be impossible: perform tracheostomy either using | ||
inhalational anaesthesia via face mask or intravenous ketamine | inhalational anaesthesia via face mask or intravenous ketamine | ||
especially if face mask anaesthesia impossible. | especially if face mask anaesthesia impossible. | ||
Blind intubation through an LMA is NOT recommended in children | Blind intubation through an LMA is NOT recommended in children | ||
due to risk of airway trauma. Attempts at FOI should be limited to two | due to risk of airway trauma. Attempts at FOI should be limited to two | ||
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to provide safe management. This is a very difficult decision and will | to provide safe management. This is a very difficult decision and will | ||
depend on the individual merits of each case. | depend on the individual merits of each case. | ||
Premedication | Premedication | ||
The use of sedative premedication in a child with a potential airway | The use of sedative premedication in a child with a potential airway | ||
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intravenous cannula, and even approach to do an inhalational | intravenous cannula, and even approach to do an inhalational | ||
induction, is also a risk. | induction, is also a risk. | ||
Therefore, a small dose of sedative premedication, such as midazolam | Therefore, a small dose of sedative premedication, such as midazolam | ||
0.3-0.5mg.kg-1 is often appropriate. Atropine is useful as an antisialogue | 0.3-0.5mg.kg-1 is often appropriate. Atropine is useful as an antisialogue | ||
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children is to maintain spontaneous ventilation until the airway is | children is to maintain spontaneous ventilation until the airway is | ||
secure. | secure. | ||
‘Awake’ techniques require good patient co-operation, which is rarely | ‘Awake’ techniques require good patient co-operation, which is rarely | ||
possible in children. Therefore, the child must be anaesthetised so the | possible in children. Therefore, the child must be anaesthetised so the | ||
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of airway problems encountered in children means the anaesthetic | of airway problems encountered in children means the anaesthetic | ||
must be tailored to the individual situation: | must be tailored to the individual situation: | ||
• Large extraoral tumours may mean a face mask will not fit | :• Large extraoral tumours may mean a face mask will not fit | ||
the child’s face, so an inhalational induction is impossible and IV | the child’s face, so an inhalational induction is impossible and IV | ||
induction/sedation must be used instead. | induction/sedation must be used instead. | ||
• Large intraoral tumours prevent laryngoscopy and the use of an | :• Large intraoral tumours prevent laryngoscopy and the use of an | ||
LMA - nasal fibreoptic intubation (FOI) should be used. | LMA - nasal fibreoptic intubation (FOI) should be used. | ||
• Conditions such a noma (cancrum oris) often cause severe | :• Conditions such a noma (cancrum oris) often cause severe | ||
limitation of mouth opening - nasal FOI is likely to be required. | limitation of mouth opening - nasal FOI is likely to be required. | ||
• Other problems such as partial mouth opening, severe retrongathia | :• Other problems such as partial mouth opening, severe retrongathia | ||
or bony abnormalities (ameloblastoma) often make laryngoscopy | or bony abnormalities (ameloblastoma) often make laryngoscopy | ||
difficult but do permit the insertion of an LMA if laryngoscopy | difficult but do permit the insertion of an LMA if laryngoscopy | ||
proves impossible. | proves impossible. | ||
• Burns contractures causing fixed flexion of the neck may be | :• Burns contractures causing fixed flexion of the neck may be | ||
released prior to intubation using ketamine anaesthesia and with | released prior to intubation using ketamine anaesthesia and with | ||
local infiltration. | local infiltration. | ||
The variety of clinical conditions mean a one-size-fits all approach is | The variety of clinical conditions mean a one-size-fits all approach is | ||
impossible. The best technique will depend on the equipment and | impossible. The best technique will depend on the equipment and | ||