Paediatric difficult airway management: Difference between revisions

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Paediatric difficult airway management (view source)

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using intravenous ketamine alone.
using intravenous ketamine alone.


Nasal fibreoptic intubation – general
<i>Nasal fibreoptic intubation – general</i>
• Maintain anaesthesia either with incremental doses of ketamine
:• Maintain anaesthesia either with incremental doses of ketamine or inhalational anaesthesia either via a nasal airway in the other nostril connected to the breathing circuit or using a specially designed facemask with a port for insertion of the fibreoptic bronchoscope.
or inhalational anaesthesia either via a nasal airway in the other
:• Use a topical vasoconstrictor to prevent bleeding from the nose during FOI, as otherwise this may make intubation impossible. Pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, or nasal packs soaked in 1:10,000 adrenaline may be used, depending on local availability.
nostril connected to the breathing circuit or using a specially
:• Apply topical lidocaine to the nose and oropharynx. Larger fibreoptic laryngoscopes often have a channel through which local anaesthesia can be injected. Alternatively an epidural catheter can be passed through the suction port (if present) and local anaesthetic injected through this. Be careful not to exceed the maximum dose of lidocaine (3mg.kg-1 i.e. 0.3ml.kg-1 of a 1% solution).
designed facemask with a port for insertion of the fibreoptic
 
bronchoscope.
The correct size of tracheal tube is critical to success. Too large a
tube will fail and require the bronchoscope to be withdrawn and the
procedure repeated. Too small may make subsequent positive pressure
ventilation difficult. It is sensible to use a small cuffed tube if available,
rather than repeated bronchoscopy.


Table 3. Size compatibility of tracheal tubes, bronchoscopes and LMAs
Table 3. Size compatibility of tracheal tubes, bronchoscopes and LMAs
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Will fit over AEC size: 7F 8F 8F 11F 11F 11F 14F
Will fit over AEC size: 7F 8F 8F 11F 11F 11F 14F
[Note: different brands of LMA vary in their internal diameter. It is important to determine the compatibility of equipment within your own department.]
[Note: different brands of LMA vary in their internal diameter. It is important to determine the compatibility of equipment within your own department.]
• Use a topical vasoconstrictor to prevent bleeding from the nose
 
during FOI, as otherwise this may make intubation impossible.
<i>Fibreoptic intubation through an LMA</i>
Pseudoephedrine, ephedrine, phenylephrine, oxymetazoline, or
nasal packs soaked in 1:10,000 adrenaline may be used, depending
on local availability.
• Apply topical lidocaine to the nose and oropharynx. Larger
fibreoptic laryngoscopes often have a channel through which local
anaesthesia can be injected. Alternatively an epidural catheter can
be passed through the suction port (if present) and local anaesthetic
injected through this. Be careful not to exceed the maximum dose
of lidocaine (3mg.kg-1 i.e. 0.3ml.kg-1 of a 1% solution).
The correct size of tracheal tube is critical to success. Too large a
tube will fail and require the bronchoscope to be withdrawn and the
procedure repeated. Too small may make subsequent positive pressure
ventilation difficult. It is sensible to use a small cuffed tube if available,
rather than repeated bronchoscopy.
Fibreoptic intubation through an LMA
There are three main techniques available:
There are three main techniques available:
1. Railroad the tracheal tube over the fibreoptic bronchoscope into
:1. Railroad the tracheal tube over the fibreoptic bronchoscope into the trachea
the trachea
:2. Railroad an airway exchange catheter (AEC) over the bronchoscope into the trachea.
2. Railroad an airway exchange catheter (AEC) over the bronchoscope
:3. Pass a soft tip wire through the suction channel of the bronchoscope into the trachea, then pass an AEC or similar over the wire as a guide for the tracheal tube.
into the trachea.
 
3. Pass a soft tip wire through the suction channel of the bronchoscope
into the trachea, then pass an AEC or similar over the wire as a
guide for the tracheal tube.
The choice of technique depends upon size of the child, the size of the
The choice of technique depends upon size of the child, the size of the
LMA, and the diameter of available bronchoscope (Table 3). Removal
LMA, and the diameter of available bronchoscope (Table 3). Removal
of the LMA once the tracheal tube is in situ may be challenging.
of the LMA once the tracheal tube is in situ may be challenging.
Options include:
Options include:
• Leave the LMA in situ
:• Leave the LMA in situ
• Use a long tracheal tube (croup tube)
:• Use a long tracheal tube (croup tube)
• Fix two tracheal tubes together over the FOB; the LMA may be
:• Fix two tracheal tubes together over the FOB; the LMA may be withdrawn over the tracheal tubes.
withdrawn over the tracheal tubes.
:• Use an AEC.
• Use an AEC.
 
Tracheostomy
<i>Tracheostomy</i>
A tracheostomy should be performed by an experienced practitioner,
A tracheostomy should be performed by an experienced practitioner,
normally an ENT surgeon. Inhalational anaesthesia or small
normally an ENT surgeon. Inhalational anaesthesia or small
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local infiltration anaesthesia. The child should breathe 100% oxygen
local infiltration anaesthesia. The child should breathe 100% oxygen
by facemask.
by facemask.
DIFFICULT AIRWAY CART
 
== DIFFICULT AIRWAY CART ==
The equipment available in different institutions will vary considerably.
The equipment available in different institutions will vary considerably.
It is good practice to organise airway equipment in such a way that
It is good practice to organise airway equipment in such a way that
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