Paediatric difficult airway management: Difference between revisions

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:• 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 ==