Securing the child's airway in the emergency department

Airway management is an important aspect of pediatric emergency care. Prompt, effective airway access can mean the difference between a good outcome and disability or death. Optimal management requires an understanding of the differences between children and adults with respect to airway anatomy and physiology and response to medications to facilitate airway access. In most cases, the emergency physician is called to secure a child's airway with little forewarning. This review details a logical and practical approach to the uncomplicated pediatric airway. Emphasis is also placed on recognition of the difficult airway and methods to render the difficulty less daunting. Good judgment and the appropriate skills are the prerequisites for success.     

Airway management

The pediatric airway and respiratory function differ from those in adults. Optimum management requires consideration of these differences, but the application of adult principles is usually sufficient to buy time in an emergency until specialist pediatric help is available. Simple airway opening techniques such as head tilt and jaw thrust are usually sufficient to open the child's airway, but there is now a range of equipment available to bypass supraglottic airway obstruction-the strengths and weaknesses of such devices are explored in this article. The role of endotracheal intubation is also discussed, along with the pros and cons of the use of cuffed endotracheal tubes in children, and methods of confirming tracheal placement of the tube.     

Anterograde endotracheal intubation with a laryngeal mask airway and guidewire in an infant with micrognathia

Tracheal intubation through a laryngeal mask airway is an alternative to secure the ventilation in patients with difficult airway. Different techniques have been described to intubate these patients. A case of micrognathia in remote location anesthesia is reported. Endotracheal intubation was unsuccessful with the conventional methods. A soft tip angiography guidewire was advanced through a laryngeal mask airway. The position of the catheter was confirmed by fluoroscopy. Laryngeal mask airway was removed after endotracheal tube was inserted over the guidewire. This technique is recommended as an alternative where fiberoptic bronchoscopy is unavailable and in emergency situations.     

Neue Behandlungskonzepte in der pädiatrischen Notfallversorgung

Technological innovations and the advent of standardized training formats, including high technology simulation laboratories have recently improved and facilitated pediatric emergency management. The proof of concept, actual impact and effectiveness of these changes have been evaluated in animal models, analysis of case series and skill improvement testing after training. In one of the most significant advances, efficient intraosseous vascular access can be established in less than 1 min using an electrical hand-held drill. Pediatric respiratory insufficiency can usually be managed with respiratory support via a face mask and bag; however, in patients with a difficult airway, laryngeal masks are an extremely useful device for airway management which can be trained with relative ease. Intubation is suitable only for physicians with relevant expertise. Additional escalation strategies for respiratory support include non-invasive ventilation prior to intubation. The current guidelines of the European Resuscitation Council recommend a chest compression-ventilation ratio of 15:2 which will result in improved coronary perfusion and higher training efficiency. Pharmacological resuscitation with adrenalin should only be performed using standard dosage via intravenous or intraosseous access. Hypothermia for neuroprotection after successful resuscitation of children has been shown to be effective for term newborn infants but currently no general recommendations for the pediatric population are possible. In the absence of an intravenous access, nasal administration of drugs results in rapid resorption and can be used for anticonvulsive treatment or even for analgesia/sedation. Crucial for successful treatment of pediatric septic shock is early and aggressive intravenous fluid resuscitation (up to 60 ml/kg) using chrystalloid solutions, so-called early goal directed therapy. Point-of-care ultrasound meanwhile significantly contributes to improved results for in-hospital pedriatric emergency management. In this paper, recommendations of pediatric and emergency societies are provided, the current literature is discussed and personal experience is reported in selected topics.     

Chest physical therapy, breathing techniques and exercise in children with CF

Chest physiotherapy in the form of airway clearance techniques and exercise has played an important role in the treatment of cystic fibrosis. Until the 1990s the primary airway clearance technique used was postural drainage combined with percussion and vibration (PD&P). It was introduced into the treatment of CF with little evidence to support its efficacy and once established, it has been difficult ethically to perform a study comparing PD&P to no treatment. A common question, yet unanswered is when should it be commenced, especially for the newly diagnosed asymptomatic CF patient? Recently, the technique of PD&P has been modified to include only non-dependant head-down positioning due to the detrimental effects of placing a person in a Trendelenburg position. In the 1990s other airway clearance techniques gained popularity, in that they could be performed independently, in a sitting position and avoided many of the detrimental effects of PD&P. These techniques include the Active cycle of breathing technique, formally called the Forced expiration technique and Autogenic drainage. Both these breathing techniques aim at using expiratory airflow to mobilize secretions up the airways and incorporate breathing strategies to assist in the homogeneity of ventilation. Studies suggest that both these techniques are as effective if not more effective than as PD&P and offer many advantages over PD&P. It has been suggested that exercise can be used as an airway clearance technique; however the literature does not support this. Rather, when exercise is used in addition to an airway clearance technique there is enhanced secretion removal and an overall benefit to the patient. Further research needs to be directed at assessing the effects of an airway clearance technique on the individual patient using appropriate outcome measures.     

Effect of salbutamol in infants with wheezy bronchitis.

Using the technique of whole body plethysmography, lung mechanics were measured in a group of infants with wheezy bronchitis. Compared with a group of normal infants previously studied, airway resistance and thoracic gas volume were found to be raised. Nebulized salbutamol was then administered and measurements were repeated when it was found that there was no objective improvement. It is concluded that salbutamol may not be an effective form of treatment of wheezy bronchitis in young infants and the reasons for this are discussed.     

Retropharyngeal abscesses in children: a 10-year review

Retropharyngeal abscess is a rather rare, deep-neck infection of children and may seriously compromise the airway and mimic other diseases. A retrospective review of 17 cases of retropharyngeal abscess presenting to The Children's Hospital, Denver, from 1976 to 1986 was performed. Nine children (56%) had stridor or airway obstruction. Seven patients (41%) had perforations of their hypopharynx or esophagus, including two neonates (most likely associated with intubation attempts). Two patients presented in the emergency department with a tentative diagnosis of "epiglottitis," while another referred to as having "persistent fever" was found to have a needle embedded in the hypopharynx. Fourteen children (81%) were brought to the operating room for examination and/or drainage of the abscess under general anesthesia. One child received an elective tracheotomy, and two others remained intubated postoperatively, pending resolution of their airway compromise. X-rays of the lateral neck were confirmatory in all these cases, with an unusually high incidence of "air/fluid levels," probably reflecting the corresponding large number of perforations of the hypopharynx or esophagus with subsequent communication into the retropharyngeal space.     

Traumatic Emergencies Involving the Pediatric Airway

This article has outlined unique characteristics of the pediatric larynx that should be considered in the setting of neck trauma and has discussed how different types of external neck trauma (blunt vs penetrating) can result in a spectrum of injuries to the pediatric airway and important adjacent structures. For a child with an acutely injured, unstable airway, an orotracheal airway should, if possible, be established with either an endotracheal tube or rigid bronchoscope before any attempt to create a surgical airway. After airway stabilization, other priorities include consideration of cervical vascular and esophageal injuries. A predetermined, logical, stepwise approach by emergency department personnel toward the management of both the stable and unstable injured pediatric airway is recommended in an attempt to reduce morbidity and mortality from this uncommon, but potentially devastating, type of injury.     

Slide thyrocricotracheoplasty: a novel surgical technique for congenital laryngeal atresia

The aim of this study was to introduce a new surgical technique for the correction of congenital laryngeal atresia. A female baby had laryngeal atresia at birth and received emergency tracheostomy at another hospital. The baby visited our hospital at 7 months of age for corrective surgery of airway obstruction. We used a new surgical technique for reconstruction of her airway, the slide thyrocricotracheoplasty, which was a modification of slide tracheoplasty and anterior cricoid split. The extubation was successful at the postoperative fifth day, and the baby was discharged on the 33rd day after operation. The serial follow-up bronchoscopy on the fourth and 18th postoperative months revealed good healing and normal growth of tissue at operation site without stenosis and granulation. Slide thyrocricotracheoplasty produced a desirable result and offered the same advantages as slide tracheoplasty. The authors believe that this technique offers an efficient surgical procedure for the single-staged correction of congenital laryngeal atresia.     

Rapid sequence intubation of the pediatric patient. Fundamentals of practice

Rapid-sequence intubation and rapid sequence induction of general anesthesia are synonyms and refer to the technique of choice for tracheal intubation in many pediatric patients in the emergency department. The principles of safe practice and basic standards of care uniformly apply to all clinical situations in which the technique is performed. RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation. The technique is a prescribed protocol that can be modified slightly by the clinical circumstances. RSI is designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses to direct laryngoscopy and tracheal intubation, and reduce the risk for pulmonary aspiration. Optimal performance requires appropriate training and knowledge, technical skill, and sound medical judgment. Medical and airway evaluation, careful patient selection, recognition of the need for consultation or safer alternatives, thorough familiarity with appropriate drug management, and attention to detail are essential for minimizing the risk for adverse complications. RSI with a rapid injection of preselected dosages of an anesthetic induction agent and muscle relaxant is the pharmacologic technique of choice. Premedication should not be routinely used. Anticipation, recognition, and management of complications are inherent to the competent delivery of all medical care. The unanticipated difficult airway is arguably the most severe complication of RSI, and all individuals performing the technique must prepare in advance a specific plan for this scenario. As with all such skills or procedures, a quality assurance program is important to monitor care, and individuals practicing RSI need to take appropriate steps to maintain competence.     

Rapid sequence anesthesia induction for emergency intubation

Emergency intubations are done for a variety of reasons in the emergency department (ED). In some patients, a rapid, controlled induction of anesthesia is useful to facilitate intubation and to reduce the complications of intubation. This is referred to a rapid sequence induction (RSI) in the anesthesia literature. Atropine, thiopental, fentanyl, diazepam, ketamine, vecuronium, succinylcholine, other drugs and their applications for RSI are described. The purpose of this article is to describe the use of RSI in the airway management of ED patients. Nineteen pediatric patients requiring emergency intubation were intubated using RSI with vecuronium and thiopental. Actual intubation difficulty using RSI was significantly less than the anticipated intubation difficulty without RSI. There were no complications caused by intubation or RSI that had a significant impact on patient outcome. We feel that a sedative in combination with vecuronium represents the most optimal means of achieving RSI in the ED setting. Although the induction of general anesthesia is best done by anesthesiologists, emergency physicians are often the most experienced physicians immediately available to manage an airway in a critical emergency. An objective protocol such as that described will make it easier for emergency physicians to perform this procedure when needed.     

Magnetic resonance imaging of obstructive sleep apnea in children

Sleep-disordered breathing has a spectrum of severity that spans from snoring and partial airway collapse with increased upper airway resistance, to complete upper airway obstruction with obstructive sleep apnea during sleeping. While snoring occurs in up to 20% of children, obstructive sleep apnea affects approximately 1–5% of children. The obstruction that occurs in obstructive sleep apnea is the result of the airway collapsing during sleep, which causes arousal and impairs restful sleep. Adenotonsillectomy is the first-line treatment of obstructive sleep apnea and is usually effective in otherwise healthy nonsyndromic children. However, there are subgroups in which this surgery is less effective. These subgroups include children with obesity, severe obstructive sleep apnea preoperatively, Down syndrome, craniofacial anomalies and polycystic ovarian disease. Continuous positive airway pressure (CPAP) is the first-line therapy for persistent obstructive sleep apnea despite previous adenotonsillectomy, but it is often poorly tolerated by children. When CPAP is not tolerated or preferred by the family, surgical options beyond adenotonsillectomy are discussed with the parent and child. Dynamic MRI of the airway provides a means to identify and localize the site or sites of obstruction for these children. In this review the authors address clinical indications for imaging, ideal team members to involve in an effective multidisciplinary program, basic anesthesia requirements, MRI protocol techniques and interpretation of the findings on MRI that help guide surgery.     

Tracheostomy in infants: parent education for home care

Children with tracheostomies are increasingly discharged home for continued care by their parents. Nurses are responsible for providing these parents with the extensive education required for a smooth and successful transition to home care. This article is intended to help neonatal and pediatric nurses to effectively prepare the parents of an infant with a tracheostomy to provide safe, quality care to their child after being discharged from an acute care setting to their home. This article discusses the knowledge, attitudes, and skills the parents are required to acquire prior to the infant's discharge. Home ventilation, airway management, suctioning, tracheostomy care, emergency management, safe home environment, equipment for continuous or intermittent ventilation, and supplies necessary for care are some of the topics discussed.     

Intraosseous infusion of hypertonic glucose and dopamine

Intraosseous infusion of drugs for resuscitation and of fluids has been advocated as an alternate emergency technique to intravenous infusion. The reliability of intraosseous infusion of many substances has not been established. Glucose and dopamine hydrochloride are two commonly used emergency drugs in pediatric practice that have not been carefully studied when administered into the bone marrow. In an animal model, we compared the response of an intraosseous injection of hypertonic glucose with that of an intravenous injection of hypertonic glucose. Serum glucose measurements following the injection revealed both routes of administration to be effective. A dopamine infusion was then administered through the bone marrow for 20 minutes. A statistically significant rise in blood pressure was observed two minutes after initiation of the infusion. Intraosseous infusion of hypertonic glucose and dopamine is an effective route by which to administer these medications and is potentially useful in emergency situations in which intravascular access is delayed.     

Intraosseous succinylcholine for orotracheal intubation

Within the past few years, the use of intraosseous infusions has increased as a means of achieving rapid vascular access. Although initially used for fluid administration, the intraosseous administration of several drugs has been shown to be an effective alternative to the intravenous route. We present two cases of the intraosseous administration of succinylcholine (1 mg/kg) for emergency airway management in children. Intraosseous succinylcholine resulted in adequate intubating conditions within 45 seconds.     

Airway infectious disease emergencies

Upper and lower respiratory infections are encountered commonly in the emergency department. Visits resulting from occurrences of respiratory disease account for 10% of all pediatric emergency department visits and 20% of all pediatric hospital admissions. Causes of upper airway infections include croup, epiglottitis, retropharyngeal abscess, cellulitis, pharyngitis, and peritonsillar abscesses. Lower airway viral and bacterial infections cause illnesses such as pneumonia and bronchiolitis. Signs and symptoms of upper and lower airway infections overlap, but the differentiation is important for appropriate treatment of these conditions. This article reviews the varied clinical characteristics of upper and lower airway infections.     

Surgical aspects of tracheostomy in children

Tracheostomy involves the surgical formation of a stoma between the trachea and the skin. It is classically thought of as a treatment to alleviate airway obstruction; however, its clinical applications are varied and include long-term ventilatory support, being an aid in pulmonary toilet and use as a covering procedure during airway surgery. In this article, we review the surgical aspects of tracheostomy, including preoperative considerations, tracheostomy tube choice, operative technique and postoperative complications. Postoperative care of the child with a tracheostomy will also be discussed.     

Evaluation of the performance of general emergency physicians in pediatric emergencies: Obstructive airway diseases,seizures, and trauma

BACKGROUND: In the Lübeck region, as is usual in Germany, hospital-based emergency physicians are called for outside emergencies. They evaluate and stabilize patients and transfer them to hospital facilities of their choice (no emergency department system). These physicians are mainly anesthesiologists, surgeons, and internists-not pediatricians. Numerous quality management studies have shown an overall excellent performance of this system, but it has not been evaluated for pediatric emergencies. PATIENTS AND METHODS: In a prospective, observational study conducted over a 1-year period, all pediatric emergencies (patient age < 15 y) treated by the emergency physician service were studied. A syllabus with standards of care for children with trauma, obstructive airway disease, and seizures was distributed. In accordance with this syllabus, the actions taken were documented by the emergency physicians, and the cases were documented as life threatening or not and were classified as "trauma," "obstructive airway disease," "seizures," or "other" by the admitting pediatric intensivists and surgeons. The admitting attending physician compared these data and evaluated whether the standard management required by the syllabus was followed. RESULTS: A total of 422 pediatric cases out of 11,605 emergencies (3.5%) were recorded (147 [34.8%] trauma patients, 41 [9.7%] patients with obstructive airway disease, and 108 [25.6%] patients with seizures). Of the pediatric patients, 20.5% had life-threatening conditions; three children died before arrival, and the others required treatment in the intensive care unit. In 25% of trauma patients, deficiencies in primary treatment were observed: no documentation of neurologic status in 10.6%, no cervical immobilization in 15% of head trauma patients, and no adequate analgesia in 7%. In 25% of seizure patients, neurologic status was not documented, although treatment was in accordance with the standard of care. The worst results were observed in infants with obstructive airway disease: no documentation of oxygen saturation in 71.4%, no oxygen therapy despite hypoxemia in seven of 12 patients, and overall therapy not in accordance with the standard of care in 50%. CONCLUSIONS: The high quality of the emergency physician service documented for adults is not reproduced in the pediatric population. Trauma and seizures with similarities to adult cases are handled in a fair manner. However, the most important pediatric diagnostic entity of obstructive airway disease is often not treated adequately. Intensified educational programs for emergency physicians are warranted.     

Pediatric airway management

The approach to pediatric airway management should be systematic and well planned. This article will describe the steps in appropriate airway management, from the prehospital to the emergency department (ED) setting. These steps include clinical assessment, preparation of equipment and staff, and a progression through a series of interventions designed to address the clinical condition of the patient. Each intervention is followed by a reassessment. Prehospital airway management is distinetly different from the ED man agement of the airway and must take into account the shill level of the providers, demographics of the emergency medical services (EMS) system, and the risks and benefits of each planned intervention. A good foundation of basic skills, such as understanding of pediatric airway-anatomy, head positioning, and correct bag-valve-mask or bag-mask ventilation (BVM), arc necessary for appropriate airway management. The majority of patients requiring endotracheal intubation (ETI) can be successfully intubated with rapid sequence intubation (RSI). A difficult airway may occasionally be encountered, and the emergency physician (EP) must have alternative methods for the support of ventilation and oxygenation if BVM and ETI fail.     

Pediatric advanced life support

Advanced life support (ALS) includes all the procedures and maneuvers used to restore spontaneous circulation and breathing, thus minimizing brain injury. The fundamental steps of ALS are airway control with adjuncts, ventilation with 100% oxygen, vascular access and fluid and drug administration, and monitoring to diagnose and treat arrhythmias. Airway control can be achieved by means of oropharyngeal airway, endotracheal intubation, and alternative methods (laryngeal mask and cricothyroidotomy). Vascular access can be achieved by the peripheral venous, intraosseous, central venous, and tracheal routes. The most frequent rhythms found in children with cardiorespiratory arrest are nonshockable (asystole, severe bradycardia, pulseless electrical activity, and complete atrioventricular block). In these cases, adrenaline continues to be the essential drug. Currently, low adrenaline doses (0.01 mg/kg IV and 0.1 mg/kg intratracheal administration) are recommended throughout the resuscitation period. Amiodarone (5 mg/kg) is the drug of choice in cases of ventricular fibrillation refractory to electric shock. The treatment sequence for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) is one 4 J/kg electric shock, followed by cardiopulmonary resuscitation (chest compressions and ventilation) for 2 minutes with subsequent reassessment of the electrocardiographic rhythm. Adrenaline must be administered immediately before the third electric shock and subsequently every 3-5 minutes. Amiodarone must be administered immediately before the fourth shock.