Pediatric Airway Management Research Articles

Paediatric procedural sedation for radiological imaging

Sedation is frequently undertaken for radiological imaging procedures in paediatric patients. Movement during procedure degrades all images of a particular sequence. A deeper level of sedation is needed. The sedation of children is different from the sedation of adult. The safe sedation of children for imaging procedure requires a systematic approach that includes the followings. Careful presedation health evaluation of the child with ASA classification. Appropriate fasting guidelines for sedation procedure. Detailed airway examination for any airway abnormalities that might increase the potential for airway obstruction. Adequate training and skills of sedating personnel in paediatric airway management. Age and size appropriate equipment for airway management and venous access. Adequate medications to combat adverse events. Monitoring of vital parameters during and after the procedure. A properly equipped and staffed recovery area. Recovery to presedation level of consciousness of patient before discharge from medical supervision and appropriate discharge instructions. The whole procedure should be well documented. Children who have contraindications to sedation should be selected for general Anaesthesia. This review article has been made to discuss the need for sedation of children during radiological imaging, currently practiced different regimens of sedation, safe guidelines for sedation and also covers the debate between need for GA versus sedation. DOI: http://dx.doi.org/10.3329/jbsa.v24i2.19805 Journal of Bangladesh Society of Anaesthesiologists 2011; 24(2): 70-76

The paediatric airway

Perioperative airway problems frequently result in significant morbidity and mortality in children. Therefore, proficiency in airway management is one of the most important key elements in the safe conduct of paediatric anaesthesia. This review includes important anatomical and physiological aspects of the paediatric airway, challenges encountered, and their management with commonly available resources. The importance of early recognition and treatment of anatomical or functional airway obstruction using locally adapted algorithms is highlighted. Children deemed at risk of aspiration require a controlled rapid sequence induction with sufficiently deep anaesthesia, confirmed complete muscle paralysis and intermittent ventilation prior to tracheal intubation. The benefits of a supraglottic airway device and a cuffed tracheal tube in paediatric airway management are discussed. The primary goal of mastering the paediatric airway is to ensure oxygenation and ventilation. This requires intricate knowledge, regular practice and experience.

Pediatric airway surgery: Management of laryngotracheal stenosis in infants and children

ConclusionI think the author succeeded to present in details the different technical aspects of diagnosis and treatment to provide the reader not only with well-established treatment modalities, but also with new concepts of pediatric airway management. This book could be an excellent reference for those going to deal with pediatric airway stenosis. The book achieved its goals, and to my mind it deserves to be read.

Evidence and Controversies in Pediatric Prehospital Airway Management

Thirty years after the formation of the Emergency Medical Services for Children program, prehospital pediatric airway management remains a high priority area for research. This review discusses the existing pediatric evidence base and explores current controversies regarding prehospital airway maneuvers and endotracheal intubation, airway adjuvant devices and rapid sequence and drug facilitated intubation.

Anesthetic management of Schimke syndrome

To the Editor: Schimke syndrome is a rare autosomal recessive inherited disorder that is characterized by disproportionately short stature, spondyloepiphyseal dysplasia, hyperlordosis, facial dimorphism resembling mucopolysacchariduria, progressive nephropathy, and defective cellular immunity [1, 2]. We report the anesthetic management of a 10-yearold girl with Schimke syndrome undergoing renal transplantation. It is important to perform a detailed preoperative evaluation in patients with Schimke syndrome. Special attention should be given to airway assessment because of syndrome characteristics such as short neck, microcephaly, lordosis, and facial appearance (ESM Fig. 1). As the patient had a short neck, large tongue, and dimorphic face, we prepared all equipment (different-sized laryngeal mask airways, different-sized laryngoscopes and tracheostomy sets) to be available for the management of a difficult pediatric airway. Although we inserted an appropriate oropharyngeal airway, mask ventilation of the patient was difficult even with two hands, probably because of her large tongue and short neck. After injection of a muscle relaxant, we could perform mask ventilation and tracheal intubation. We believe that we were able to use the muscle relaxant safely because we had sugammadex for rescue events. Neurological symptoms in patients with Schimke dysplasia have been described previously as transient ischemic attacks, probably related to vascular stenosis, and ulceration resulting from atherosclerosis and thrombus formation: such stroke episodes can lead to death [3]. Extra care was taken to maintain stable blood pressure during surgery. In conclusion, difficult airway management and special attention to thrombotic events and epileptic seizures are the important issues involved in anesthetic management of this syndrome.

Pediatric airway management

Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a “difficult airway.” Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.

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Management of the difficult pediatric airway with endotracheal intubation via telescopic guidance

The LaryngoscopeVolume 124, Issue 3 p. 785-788 Pediatrics Management of the difficult pediatric airway with endotracheal intubation via telescopic guidance Matthew M. Dedmon MD, PhD, Corresponding Author Matthew M. Dedmon MD, PhD Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Send correspondence to Matthew Dedmon, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. E-mail: matthew_dedmon@meei.harvard.eduSearch for more papers by this authorDerek J. Rogers MD, Derek J. Rogers MD Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Search for more papers by this authorChristopher J. Hartnick MD, MS, Christopher J. Hartnick MD, MS Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Search for more papers by this author Matthew M. Dedmon MD, PhD, Corresponding Author Matthew M. Dedmon MD, PhD Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Send correspondence to Matthew Dedmon, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. E-mail: matthew_dedmon@meei.harvard.eduSearch for more papers by this authorDerek J. Rogers MD, Derek J. Rogers MD Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Search for more papers by this authorChristopher J. Hartnick MD, MS, Christopher J. Hartnick MD, MS Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.Search for more papers by this author First published: 27 May 2013 https://doi.org/10.1002/lary.24227Citations: 1 The authors have no funding, financial relationships, or conflicts of interest to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume124, Issue3March 2014Pages 785-788 RelatedInformation

Airway management during pediatric resuscitation.

Good airway management is fundamental to pediatric resuscitation. This review focuses on the anatomy of the infant and child airway, together with techniques and equipment required to open and maintain a child's airway in an emergency. Much of the knowledge has been available for many years but newer imaging techniques are allowing more accurate assessment of the child's airway anatomy and, in some cases, challenging traditional assumptions. In addition, recent technologies are facilitating the development of equipment, such as supra-glottic airway devices, cuffed tracheal tubes and video laryngoscopes that have the potential to simplify pediatric airway management. In some cases, this may bring the provision of safer definitive airway management into the hands of non-specialists, which will, in turn, allow the delivery of earlier and better care to the sick child. Such techniques are best used together with accurate monitoring to confirm the effectiveness of any intervention. In airway management, the use of expired carbon dioxide monitoring provides absolute confirmation that pulmonary ventilation is occurring and, when used together with the techniques and equipment described above, will reduce the potential for error and increase safety and survival.

Anaesthetic challenges in a patient presenting with huge neck teratoma

Paediatric airway management is a great challenge even for an experienced anaesthesiologist. Difficult airway in huge cervical teratoma further exaggerates the complexity. This case report is intended at describing the intubation difficulties that were confronted during the airway management of a three year old girl presenting with huge neck teratoma and respiratory distress. This patient was successfully intubated with uncuffed endotracheal tubes in second attempt under inhalational anaesthesia with halothane and spontaneous ventilation. This case exemplifies the importance of careful preoperative workup of an anticipated difficult airway in paediatric patients with neck swelling to minimize any perioperative complications.

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Introduction: Adult emergency facilities are often not equipped to deal with pediatric medical crises should they arrive. Many critically ill children and infants, however, pass through such hospitals on the way to definitive management at a pediatric tertiary care center. Hypothesis: The goal of this study was to implement and evaluate a simulation-based outreach curriculum focused on the care of critically ill infants. We hypothesized that participation would result in improvements in adult emergency providers’ knowledge regarding and comfort with critically ill children. Methods: The curriculum was based upon three critical pediatric situations: abusive head trauma, pneumococcal sepsis, and congenital heart disease. A tetherless pediatric mannequin was purchased, enabling us to conduct training sessions “in-situ.” Participant demographic data was collected. Participants’ knowledge and comfort was evaluated before and after the course using a multimedia test and survey that addressed general pediatric critical illness, pediatric airway management, pediatric respiratory disease, pediatric cardiac disease, PALS algorithms, and crisis procedural skills. Course quality data were also collected. This study was exempted by the University of Lousville IRB. Results: 54 clinicians participated in the course at 6 institutions (3 physicians, 30 nurses, 1 nurse practitioner, 15 EMT’s, and 5 RT’s). Clinicians averaged 14.3 years in practice (range 0.2-40). Programs lasted approximately 3.5 hours. Participants achieved a median score of 40% on the pretest and 60% on the post test, (median 20% improvement). This change was significant by Wilcoxon signed-rank test (p-value<0.001). Comfort level scores improved from a median score of 2-3 (across all domains) to 3-4. This represented a median of 1-2 points improvement in all domains (all p-values <0.001). Program quality scores averaged 4.7-4.9/5. Conclusions: The curriculum was well-received and highly rated. We were able to achieve a statistically significant increase in participant comfort and knowledge. Questions remain regarding long-term retention of knowledge and comfort. Based on these results, we plan to expand the application of this curriculum.

A comparison of three supraglottic airway devices used by healthcare professionals during paediatric resuscitation simulation

ObjectiveThe aim of this study was to determine the best airway device among the laryngeal mask, I-gel and the laryngeal tube used by healthcare professional groups with different levels of...

972 Managing Ent Emergencies Needing Transfer to Picu: the Extended Transport Team

BackgroundPaediatric ENT emergencies are rare but can be life-threatening and challenging to manage. In UK paediatric ENT services are centralised, and adult ENT surgeons and anaesthetist provide cover in local...

Pediatric airway management: current practices and future directions

Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.

Principles of Airway Management, 4th Edition

The fourth edition of Principles of Airway Management is a comprehensive work covering virtually all aspects of the adult and pediatric airway that any professional can hope to learn from a textbook. Indeed, its 15 chapters encompass the following topics: anatomy of the airway, evaluation of the airway, basic emergency airway management and cardiopulmonary resuscitation, basic equipment for airway management, the LMA and other supraglottic devices, advanced airway devices (including fibreoptic laryngoscopes, videolaryngoscopes, stylets, and light wands), indications and preparation of the patient for tracheal intubation, techniques of intubation, the difficult airway, pediatric airway management, fibreoptically guided airway management techniques, surgical options in airway management, mechanical ventilation and respiratory care, extubation strategies, and, finally, complications of airway management. This book is well written throughout, and the comprehensive table of contents and index enable the reader to easily find information in this lengthy textbook. The tables and figures have been improved in this edition and most are of good quality. The references are up-to-date. While the preponderance of expertise in airway management can be acquired only through experience, both novices and experts alike will gain insight into airway management by consulting this book. It provides the basic information useful to the beginner and the more advanced content useful to the expert. The book strikes the right balance between theoretical and technical information, which is another important quality. The authors offer the greatest extent of practical ‘‘how to’’ information in a textbook, notably because of the numerous figures. Although this 742-page textbook is indeed quite complete, some advanced techniques, e.g., rigid bronchoscopy, jet ventilation, and lung isolation, are covered hastily and without much technical detail. This is unfortunate since an expert might consult this textbook specifically for information regarding these perhaps less commonly used techniques. In contrast, some topics, e.g., cardiopulmonary resuscitation, are reviewed in surprising detail for a textbook dealing with airway management. Overall, this fourth edition of Principles of Airway Management constitutes a very good reference for any individual or organization interested in airway management. The depth of information goes well beyond that available in more ‘‘general’’ anesthesia textbooks, such as Miller’s Anesthesia, Seventh Edition by Ronald D. Miller and Clinical Anesthesia, Sixth Edition by Paul Barash.

Development of an Instrument for a Primary Airway Provider's Performance With an ICU Multidisciplinary Team in Pediatric Respiratory Failure Using Simulation

To develop a scoring system that can assess the multidisciplinary management of respiratory failure in a pediatric ICU. In a single tertiary pediatric ICU we conducted a simulation-based evaluation in a patient care area auxiliary to the ICU. The subjects were pediatric and emergency medicine residents, nurses, and respiratory therapists who work in the pediatric ICU. A multidisciplinary focus group with experienced providers in pediatric ICU airway management and patient safety specialists was formed. A task-based scoring instrument was developed to evaluate a primary airway provider's performance through Healthcare Failure Mode and Effect Analysis. Reliability and validity of the instrument were evaluated using multidisciplinary simulation-based airway management training sessions. Each session was evaluated by 3 independent expert raters. A global assessment of the team performance and the previous experience in training were used to evaluate the validity of the instrument. The Just-in-Time Pediatric Airway Provider Performance Scale (JIT-PAPPS) version 3, with 34 task-based items (14 technical, 20 behavioral), was developed. Eighty-five teams led by resident airway providers were evaluated by 3 raters. The intraclass correlation coefficient for raters was 0.64. The JIT-PAPPS score correlated well with the global rating scale (r = 0.71, P < .001). Mean total scores across the teams were positively associated with resident previous training participation (β coefficient 7.1 ± 0.9, P < .001), suggesting good validity of the scale. A task-based scoring instrument for a primary airway provider's performance with a multidisciplinary pediatric ICU team on simulated pediatric respiratory failure was developed. Reliability and validity evaluation supports the developed scale.

A child with a difficult airway

Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway. Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential. The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.

The normal and the challenging pediatric airway

Management of a child's airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists' repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted - the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of 'cannot ventilate, cannot intubate' in children.

Audit of imaging under sedation in children

<h3>Background</h3> Children who need MRI scanning frequently need sedation in order to remain still for the procedure. This poses a number of potential problems including the organisational difficulties in ensuring that the child is admitted, sedated and scanned all in a timely, coordinated and safe manner. Hospital protocol for Imaging under sedation in children Chloral Hydrate orally (50-100 mg/Kg, max 2 g: Ref BNF 2008: 211) is prescribed to be administered 45 mins before scan. If the child is not adequately sedated 15 mins before the planned scan time then intravenous midazolam (50-100 mcg/Kg in steps up to max of 300 mcg/Kg) may be given. All sedated children must have continuous oximetry and have facilities available for bag-and-mask ventilation. <h3>Methods</h3> We conducted an audit to review our practice by examining our safety and success rates. The medical notes of 56 patients from June 2009-December 2010 were reviewed. We looked at the age, gender, date, indication, emergency/planned, oral Chloral Hydrate, IV midazolam, accompanied by SHO/SpR, success rate, complications, result, picture quality and whether any repeat scan was required. <h3>Results</h3> The majority of scans were performed as planned procedures. 54 (98%) patients received oral chloral hydrate 50-100 mg/kg and 44 (82%) of them received IV midazolam 100 mcg/kg. Only 12 (28%) of the midazolam group required a further dose. 47 (84%) had successful sedation with good quality pictures and only 4 required a repeat scan. We found that most patients were pre school children, 33 (60%) were aged 1-5 years. Half of our patients were accompanied by SpRs during the procedure and no complications were reported. The commonest indication was for seizures and the majority of scan results showed incidental findings only. <h3>Conclusions</h3> We had a high success rate when compared with published data and we considered whether this was due to the frequent use of midazolam or because Chloral Hydrate was used in conjunction with the midazolam. In addition, these children should be accompanied by a doctor competent in paediatric airway management. We believe implementation of this protocol in children is safe, successful and cost effective.

Paramedic King Laryngeal Tube Airway Insertion versus Endotracheal Intubation in Simulated Pediatric Respiratory Arrest

Introduction: Pediatric endotracheal intubation (ETI) is difficult and can have serious adverse events when performed by paramedics in the prehospital setting. Paramedics may use the King Laryngeal Tube airway (KLT) in difficult adult airways, but only limited data describe their application in pediatric patients. Objective: To compare paramedic airway insertion speed and complications between KLT and ETI in a simulated model of pediatric respiratory arrest. Methods: This prospective, randomized trial included paramedics and senior paramedic students with limited prior KLT experience. We provided brief training on pediatric KLT insertion. Using a random allocation protocol, participants performed both ETI and KLT on a pediatric mannequin (6-month old size) in simulated respiratory arrest. The primary outcomes were 1) elapsed time to successful airway placement (seconds), and 2) proper airway positioning. We compared airway insertion performance between KLT and ETI using the Wilcoxon signed-ranks test. Subjects also indicated their preferred airway device. Results: The 25 subjects included 19 paramedics and 6 senior paramedic students. Two subjects had prior adult KLT experience. Airway insertion time was not statistically different between the KLT (median 27 secs) and ETI (median 31 secs) (p = 0.08). Esophageal intubation occurred in 2 of 25 (8%) ETI. Airway leak occurred in 3 of 25 (12%) KLT, but ventilation remained satisfactory. Eighty-four percent of the subjects preferred the KLT over ETI. Conclusions: Paramedics and paramedic students demonstrated similar airway insertion performance between KLT and ETI in simulated, pediatric respiratory arrest. Most subjects preferred KLT. KLT may provide a viable alternative to ETI in prehospital pediatric airway management.