AIRWAY MANAGEMENT IN PEDIATRIC PATIENT A DISCUSSION ON RAPID SEQUENCE INTUBATION BY: - DR HIMANSHU GUL MIRANI EMERGENCY PHYSICIAN Urgent

t Care Center, Hospitals in Delhi

Airway management in a pediatric patient can be quite a daunting task. Due to the inherent anatomical and physiological differences between the adult and pediatric anatomy as summarized below, there can be a significant challenge in maintaining the airway of a child in respiratory distress. In this article I have discussed the basic differences between the adult and pediatric airway and its implications in doing airway interventions & approach of rapid sequence intubation (RSI) in pediatric age group patients.

Comparing the adult with the pediatric population:The neutral position for a child is not lying flat on the bed but being supported with a towel roll under the shoulder due to the bigger occiput, flexing the neck while lying flat. Bigger tongue mass relative to oral cavity, a conical shaped airway and narrow cricoid area, cephalad laryanx and a floppy epiglottis all make the pediatric airway anatomically different from adults. Smaller and narrower airway is also more likely to get blocked with inflammatory swelling, secretions, mucous and foreign bodies. Physiologically; lower respiratory reserve capacity, less number of type 1 muscle fibers in the intercostals, low storage of energy reserve molecules and higher

metabolic rates pressing for more demand for oxygen; predispose children to deteriorate faster than adults in the case of respiratory distress.

Assessment of the child in respiratory distress in ER:Looking at the child gives a gross idea of whether the child is in extremis or toxic or not. Appearance of the child gives a clue about the degree of his/her distress. Look for the childs muscle tone and whether s/he is moving all limbs actively, whether the child is listless or crying, look for his/her gaze. See the respiratory rate per minute and any evidence of retractions in the chest wall. Look for the childs color is it bluish or mottled or pale. A quick gross assessment of airway, breathing and circulation should be done in any child coming to ER. Airway should be looked for whether maintainable or not and necessary intervention should be done immediately, if required. Regarding breathing - normal breathing, respiratory distress and respiratory failure should be differentiated by looking at bare chest for respiratory rate, retractions and grunting .SPo2 level should also be monitored to differentiate distress and failure. Assess the overall activity level of the child. Toxic looking, distressed children should alert the treating team for a need of higher intervention. (Hospitals in Vikas Marg)

Rapid Sequence Intubation (RSI):In case the child seems to need an endotracheal tube (advance airway/intubation), anticipate early and start preparation. Always have a backup. Always anticipate a difficult airway (micrognathia ,macroglossia, cleft or high arched palate, protruding upper incisors, small mouth , limited temporomandibular joint mobility, limited cervical spine mobility) and have preparedness for fail intubations.

Start preparations by; Pre-oxygenating Establish Appropriate monitoring Establishing iv access and taking all relevant samples Get the needed medicines loaded (sedatives, paralyzing agents, analgesics ) in syringes get them labeled with drug name and amount of drug Keep ET tubes of anticipated size plus one size higher and one size lower Uncuffed ET tube and 3rd generation cuffed ET tube sizes are chosen as per the formula 4+(age in yrs)/4 If we are using traditional cuffed ET tube, 1 size smaller than the one calculated for age is chosen For premature children, size of ET tube is calculated roughly as size = {gestational age in weeks/10} Size of the little finger of the child is a rough guide to selecting the one with a similar internal diameter Get laryngoscopes of correct sizes chosen depending on approximate weight of the child and blade types straight blades are preferred in infants and toddlers, curved blades are used for children above 2 yrs of age Keep supra-glotic airway and other rescue ventilation equipments ready Keep bougie handy

Pre-oxygenation a.k.a denitrogenation:Pre-oxygenate in half sitting position/ reverse Trendelenberg position if sitting up is limited by spine pathology for duration of at least 1 minute in infants and 2-3 minutes in older age groups. Use nonrebreathing mask with high flow oxygen. Place nasopharyngeal airways and if comatose also insert oropharyngeal airway while preoxygenating to ensure good reservoir build up in the airway. In case of difficulty, consider using Bag Mask Ventilation.

Preoxygenating liberally helps to delay desaturation below 95% for a longer duration.

Arm yourself to prevent any complication during intubation:Be ready to tackle the following common complications in peri-intubation period. 1. Hypotension commonly seen due to sedating and inducing agents like benzodiazepines, barbiturates etc. It can be handled by using their minimum possible dose, giving a volume resuscitation incase of hypotensive episode and keeping Phenylephrine ready to counter any hypotension. 2. Desaturation - its prevented by using liberal pre-oxygenation and nasal canula to give continuous oxygen during the entire course of RSI 3. Bradycardia caused by manipulation of neck structures in kids, its tackled by giving Atropine injection. Its advocated as a premedication in children under 2 yrs of age. 4. Acidosis may be due to incorrect ventilator setting, with low respiratory rate. Its needs assessment by ABG post intubation and setting clinically correct respiratory rate. Sodium bicarbonate may be used in metabolic acidosis, which counters intravascular acidosis and its degradation product i.e. Carbon Dioxide hence produced acts to stimulate respiratory centre to exhale it thus increasing the respiratory drive. But over correction with bicarbonate MUST be avoided as it can further jeopardize acidosis by CO2 release and incomplete flushing of the same. 5. Aspiration it may be cause of the distention caused by bag mask ventilation or underlying pathology of obstruction in the gut. Its avoided by applying cricoids pressure, but excess of pressure must not be applied to block the childs airway by external compression.

Pretreatment:Agents like lidocaine in head injury to reduce ICP, atropine - for bradycardia, metoclopromide - for preventing aspiration are given looking at the patient condition and may be optional.

Inducing agent:Etomidate (0.3 mg-0.5mg/kg) is a preferred agent due to its rapid action, short duration of action and no cardiorespiratory effects ( should be avoided in patient with septic shock). Ketamine (1mg/kg) is a good option as it releases catecolamines, causing rise in BP and heart rate and bronchodilation. Propofol (1-2 mg/kg) is also a good agent, but has a cardiodepressive effect resulting in hypotension. Benzodiazepines like Midazolam (0.1-0.3mg/kg) produce amnesia, sedation and hypnosis, have anxiolytic and anticonvulsant effect. They too cause marked cardiopulmonary depression. Barbiturates like Thiopental and Methohexitol have rapid onset and are short acting (5-10 mins) but cause hypotension and respiratory depression.

Paralyzing agent:Succinylcholine (1mg/kg) is a useful agent. Its quick action (30-45 secs) and short duration (4-6 mins) make it an ideal paralyzing agent. But it is known to hyperkalemia, arrhythmias and masseter spasm. It is contraindicated in demyelinating neuromuscular disases, burns, known case of hyperkalemia, crush injury etc Rocuronium (0.3-1mg/kg) a non depolarizing agent is also a rapidly acting agent but it acts for a longer duration. Its free of all the side effects of succinylcholine and can be used safely in patients where succinylcholine is contraindicated.

Place the ET tube:Use bougie. While using a bougie ensure to have a tactile appreciation of the tracheal rings. Also, while advancing the bougie in the trachea, the insertor would meet resistance in the tracheal tree. This sensation is absent in case of esophageal insertion of the bougie. Rotate the ET tube while sliding on the bougie to prevent laryngeal soft tissue from trapping in the space between bougie and the ET tube. If needed ask someone to pull on the right angle of the mouth of the patient to give the doctor more space to manipulate. Giving jaw thrust while intubating may help to improve view. Dont forget to give continuous nasal oxygen throughout the RSI procedure.

Position confirmation:Auscultate both axilla and over the epigastrium. There are a lot of conducted sounds so a loud sound may be heard in the epigastric area too preferably confirm the placement with multiple methods before pulling out the tube. If one notices decreased sounds on left side, it may be due main stem intubation. Use End tidal CO2 assessment and colorimetric tests to further corroborate evidence of correct tube placement. Colorimetric tests may be false if the lung perfusion is low as may be the case in cardiac arrest and massive pulmonary embolism. Do a chest X-ray to see the tube. It should be about 2 cms above the carina. Do an ABG to assess the blood gas status and adjust ventilator setting accordingly.

Post intubation assess for the following: Displacement Pneumothorax Main stem intubation Adequate Chest Rise Give sedatives and analgesics (sedation and analgesia)

Failed intubation:Failed intubationshould be suspected when patient continoulsly desaturating inspite of bagging , no reading inETCO2 monitor or there is no adequate chest expansion. In that condition , Immediately remove the tube Reoxygenate the patient with bag and mask ventilation. Use dual nasophayngeal airway and bag mask ventilation. May consider using additional oropharyngeal airway if the patient is unconscious. Reintubate or use supraglotic airway devices like LMA if needed. In case of difficult airway requiring surgical airway intervention, remember: Surgical cricothyrotomy is not to be performed in children under 8 yrs of age Needle cricothyrotomy is a temporary method and a definite intervention would be needed once its done. It can only help to buy time.

Conclusion:Pediatric airway management can be quite challenging to the best trained hands. Since its usually not that common as in adults and when needed, its also associated with a much poorer prognosis, its advisable to hold frequent drills in the ER.

A well synchronized effort, with a good back up plan for a failed intubation attempt would always be handy and a mark of well orchestrated ER team!