Prevention of accidental extubation in newborns

Maintaining endotracheal intubation is critical to treating respiratory failure in newborns. To reduce accidental extubations in our neonatal intensive care unit, a prospective comparison of rates of extubation was made between two taping methods and whether or not a head restraint was used. One tape method was significantly better at preventing accidental extubations. Head restraint was not a benefit when used prospectively. Factors that preceded or were associated with accidental extubation included the time intubated, infant agitation, endotracheal tube suctioning, the infant turning its head, chest physiotherapy, loose tape, too short a tube between lip and adapter, weighing, and endotracheal tube taping. This information and the study design are valuable in developing strategies to minimize accidental endotracheal extubation and the subsequent risks of airway injury and subglottic stenosis in sick newborns.     

Mechanical ventilation in pediatrics (III). Weaning, complications and other types of ventilation. Compications of mechanical ventilation

Mechanical ventilation can produce multiple complications. The most important acute complications are mechanical problems (respirator failure, problems with the connections and circuit, incorrect parameters or alarms), problems in the airway (disconnection, extubation, mal-positioning of the endotracheal tube, leaks, nose erosions, obstruction of the endotracheal tube due to secretions or kinking, mainstem bronchus intubation, bronchospasm, postextubation croup), pulmonary complications (ventilator-induced lung injury with barotrauma, volutrauma and biotrauma), hemodynamic complications, nosocomial infections (tracheobronchitis, pneumonia, otitis, sinusitis), failure of adjustment of the respirator to the patient, and nutritional complications. The most important chronic problems are subglottal stenosis, chronic pulmonary injury, and psychological alterations.     

Anesthesia in cancrum oris

A case report describing anesthetic management of a child suffering from cancrum oris is described. The patient presented with respiratory obstruction with necrotic lesions of the skin surrounding the mouth and of oral mucosa. Generalised septicemia was present. It was not possible to pass an endotracheal tube and anesthesia was therefore achieved with intravenous infusion of ketamine without the use of an airway or endotracheal tube.     

Anesthesia in cancrum oris

A case report describing anesthetic management of a child suffering from cancrum oris is described. The patient presented with respiratory obstruction with necrotic lesions of the skin surrounding the mouth and of oral mucosa. Generalised septicemia was present. It was not possible to pass an endotracheal tube and anesthesia was therefore achieved with intravenous infusion of ketamine without the use of an airway or endotracheal tube.     

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.     

Review of intubation in severe laryngotracheobronchitis

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.     

The endotracheal tube air leak test does not predict extubation outcome in critically ill pediatric patients

OBJECTIVE: Endotracheal tube air leak pressures are used to predict postextubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine whether the absence of an endotracheal tube air leak (air leak test >/=30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children. DESIGN: Prospective, blinded cohort. SETTING: Multidisciplinary pediatric intensive care unit of a university hospital. PATIENTS: Patients younger than or equal to 18 yrs and intubated >/=24 hrs. INTERVENTIONS: The pressure required to produce an audible endotracheal tube air leak was measured within 12 hrs of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during air leak test measurements. MEASUREMENTS AND MAIN RESULTS: The need for reintubation (i.e., extubation failure) was recorded during the 24-hr postextubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9 of 59). Seven patients were treated for postextubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hrs, p = 0.03. Extubation success was associated with the use of postextubation noninvasive ventilation (p = 0.04). The air leak was absent for the duration of mechanical ventilation (i.e., >/=30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value 27%, 95% confidence interval 6-60). The air leak test was >/=30 cm H2O before extubation in 47% (28 of 59) of patients yet 23 patients extubated successfully (negative predictive value 18%). CONCLUSIONS: An endotracheal tube air leak pressure >/=30 cm H2O measured in the nonparalyzed patient before extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube.     

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.     

Tracheitis in pediatric patients

Despite the advances that have been achieved in supportive pediatric intensive care, tracheitis remains a significant cause of reversible upper-airway obstruction in pediatric patients. This discussion highlights the epidemiology and clinical presentation of tracheitis in the twenty-first century and reviews diagnostic and therapeutic modalities. The gold standard for therapy remains supportive airway management in conjunction with appropriate antibiotic therapy. Finally, the unique challenges of diagnosis and treatment of tracheitis in the technology dependent child with an existing artificial airway (endotracheal tube or tracheostomy) are addressed.     

Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during noninvasive mask ventilation

Colorimetric carbon dioxide detectors are useful indicators of proper endotracheal tube placement. We have found that they also are helpful during bag and mask ventilation as an indicator of a patent airway. In this report, we describe our experience with these devices for use during preintubation airway stabilization as observed during videotaped performances from a prospective, randomized trial of intubation premedication.     

Rescue use of DNase in critical lung atelectasis and mucus retention in premature neonates

Excessive or thick pulmonary secretions are a common clinical challenge in the neonatal population. Mucus accumulation can cause many life-threatening complications, including plugging of the endotracheal tube and increasing the risk of pulmonary infections. We report 3 premature neonates who had critical pulmonary collapse secondary to mucous plugging. Different conventional methods to liquefy mucus and facilitate removal of secretions were exhausted to no avail. The rescue use of DNase was effective in reestablishing airway patency. Thus, this drug could be a valuable tool in treating atelectasis and mucus-plugging in mechanically ventilated, premature neonates.     

The role of the nasopharyngeal prong in craniofacial disorders in particular the Pierre Robin sequence

There are a wide range of surgical and maxillofacial options to alleviate upper airway obstruction in children with craniofacial disorders. The nasopharyngeal prong (NPP) is a simple idea where the airway obstruction arising from the posteriorly placed tongue secondary to a small mandible can be overcome quickly and without resorting to more invasive surgical procedures.The role of the NPP is of particular interest in Robin sequence (RS). RS describes a congenital anomaly with retrognathia (often with associated U-shaped cleft palate) where in some children the tongue and small jaw can significantly impact on airway patency with upper airway obstruction. The NPP is a modified endotracheal tube, of ideal diameter and cut to a desired length that can bypass the airway obstruction and regain patency to the upper airway. RS has a natural history of mandibular growth and resolution of the symptoms with time and thus the NPP presents a medium term solution precluding the need in selected children of more permanent and potentially unnecessary surgical procedures.The role of the NPP in other craniofacial disorders (either as a temporary solution or longer term option) requires further research.     

Laryngeal function and nasal ventilatory support in the neonatal period

Nasal application of positive airway pressure, either intermittently or continuously, is increasingly used in the neonatal period. An important difference however when using a nasal interface as opposed to an endotracheal tube for ventilatory support is the interposition of the larynx. Recent animal studies from our laboratory showed that nasal ventilatory support in the neonatal period can significantly impact laryngeal function. This includes active laryngeal closure against intermittent positive pressure ventilation, which can limit lung ventilation, and inhibition of non-nutritive swallowing, which may delay swallowing maturation. Those novel findings are highly relevant to neonatal respiratory care. Additional studies are underway to uncover both the mechanisms involved and consequences on lung ventilation and swallowing function.     

Pressure-induced angioedema associated with endotracheal tube: successful treatment with epinephrine in two cases

Pressure-induced urticaria is a non-immunoglobulin E-mediated type of urticaria. Some patients only have angioedema, and the term pressure-induced angioedema (PIA) is more appropriate for them. PIA has not previously been reported in association with endotracheal tube. Here we describe two patients who developed PIA after endotracheal intubation. There were no histories of angioedema, drug and food allergy in both patients. Tests for specific aero-allergens and latex were negative. Serum total immunoglobulin E and C4 levels were in normal ranges. Antihistamines and intravenous steroid therapy were ineffective. Angioedema regressed with intravenous epinephrine infusion and did not relapse after extubation. Conclusion: We suggest that endotracheal tubes can cause PIA. Epinephrine therapy should be used early at treatment, especially in the patients who are at great risk for life-threatening airway problems.     

Techniques and complementary techniques. Intubation, sedation and adaptation to mechanical ventilation

Endotracheal intubation consists on placing a tube in the trachea either through the mouth (orotracheal intubation) or through the nose (nasotracheal intubation). Although maintaining the airway patent and providing adequate ventilation are not synonymous with intubation, this procedure provides a closed ventilation system while ensuring patency and protecting the airway. Intubation is fairly safe in oxygenated and physiologically stable patients but it is not free from serious complication and consequently it should always be considered as a dangerous technique, especially in critically-ill patients. In addition, given that the anatomy of the airway in children differs according to age, the techniques used to intubate show considerable variations. For all these reasons and despite the often urgent nature of airway problems in children, the placement of an endotracheal tube must be approached in a deliberate and calm manner if trauma to the airway and patient instability are to be avoided. Thus, whenever circumstances permit, intubation should be carefully prepared with assessment of factors that might cause problems such as the indication for intubation, possible airway abnormalities, risk of aspiration, and hemodynamic, respiratory and neurological status. Such and evaluation allows the most appropriate intubation technique to be chosen.     

Techniques and complementary techniques. Endotracheal aspiration, bronchial brushing and bronchoalveolar lavage

The aim of endotracheal aspiration is to eliminate secretions in patients with an artificial airway. All children with mechanical ventilation must undergo this procedure periodically. The frequency of aspiration depends on the type and quantity of the respiratory secretions and on the patient's clinical status. Aspiration should be performed by two people to maintain a greater degree of asepsis and to optimize stability of the airway and ventilation. Closed aspiration systems are available that allow aspiration without the need to disconnect the patient through a single probe that is constantly protected by a plastic sleeve and isolated from external environment. The most important risks of endotracheal aspiration are hypoxemia, mucosal injury, bronchospasm, arrhythmias, perforation of the airway with development of pneumothorax, accidental extubation, and infections. Bronchial brushing with a protected catheter and brochoalveolar lavage are used to analyze pulmonary infections. These techniques can be performed blind or through fibrobronchoscopy. They can also be used for the diagnosis of noninfectious pulmonary diseases such as alveolar proteinosis, alveolar hemorrhage or histiocytosis. Their adverse effects are similar to those of endotracheal aspiration.     

Possible risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation.

OBJECTIVE: To analyze the role of risk factors associated with moderate or severe airway injuries in children who underwent endotracheal intubation. DESIGN: Prospective cohort study. SETTING: Pediatric intensive care unit. PATIENTS: All patients who required endotracheal intubation during a 25-mo period (October 1999 through October 2001). Exclusion criteria were death before extubation and weight of <1250 g. INTERVENTIONS: Airway endoscopy at extubation and reevaluation for those reintubated. MEASUREMENTS: Relative risks and 95% confidence intervals were calculated in the univariate risk factor analysis (age, sex, organ failure, difficult intubation, tube size, reintubation, tube changes, and duration of intubation). p Values were calculated from the chi-square test with Yates' correction or for trend, and a value of <.05 was considered significant. To define which of the main variables were independently associated with the outcomes of interest, we used logistic stepwise forward modeling. The Mantel-Haenszel method was used for the stratified analysis between the two independently associated variables. RESULTS: The study population consisted of 215 patients (61 newborns and 154 children). Moderate lesions occurred in 24.2% of patients, and severe lesions in 10.7% of patients. Risk factors associated with moderate or severe injury in a univariate analysis were age, sex, organ failure, reintubation, tube changes, and longer duration of intubation. According to Mantel-Haenszel stratified analysis results, reintubation and tube changes were the only variables independently associated with the outcomes. CONCLUSIONS: We concluded that to prevent morbidity secondary to airway injury, efforts should be directed to avoid reintubation and tube changes in the concerned scenario.     

Foot length, an accurate predictor of nasotracheal tube length in neonates.

BACKGROUND: Existing guidelines for optimal positioning of endotracheal tubes in neonates are based on scanty data and relate to measurements that are either non-linear or poorly reproducible in sick infants. Foot length can be measured simply and rapidly and is related to a number of external body measurements. OBJECTIVES: To evaluate the relation of foot length to nasotracheal length in direct measurements at post mortem examinations, and then compare its clinical relevance with traditional weight based estimates in a randomised controlled trial. METHODS: The dimensions of the upper airway were measured at autopsy in 39 infants with median (range) postmenstrual age and birth weight of 32 (24-43) weeks and 1630 (640-3530) g. The regression equations with 95% prediction intervals were calculated to estimate the optimal nasotracheal length from foot length. In a randomised trial, 59 neonates were nasally intubated according to foot length and body weight based estimates to assess the achievement of "optimal" and "satisfactory" tube placements. RESULTS: In the direct measurements of the airway at autopsy, foot length was a better predictor of nasotracheal distances (r(2) = 0.79) than body weight, gestational age, and head circumference (r(2) = 0.67, 0.58, and 0.60 respectively). Measurement of foot length was easy and highly reproducible. In the randomised controlled trial, there were no significant differences between the foot length and body weight based estimates in the rates of optimal (44% v 56%) and satisfactory (83% v 72%) endotracheal tube placements. CONCLUSIONS: Foot length is a reliable and reproducible predictor of nasotracheal tube length and is at least as accurate as the conventional weight based estimation. This method may be particularly valuable in sick unstable infants.