20 Practical procedures: airway and breathing



20.2 NASOPHARYNGEAL AIRWAY INSERTION


Assess for any contraindications such as a base of skull fracture.



1 Select an appropriate size (length and diameter) of airway (see Chapter 5).

2 Lubricate the airway with a water-soluble lubricant.

3 Insert the tip into the nostril and direct it posteriorly along the floor of the nose (rather than upwards).

4 Gently pass the airway past the turbinates with a slight rotating motion. As the tip advances into the pharynx, there should be a palpable ‘give’.

5 Continue until the flange rests on the nostril.

6 If there is difficulty inserting the airway, consider using the other nostril or a smaller size than the original estimate.

7 Recheck airway patency.

8 Finally, provide oxygen, considering ventilation by pocket mask or bag-and-mask.

20.3 OROTRACHEAL INTUBATION (INCLUDING RAPID SEQUENCE INDUCTION)


As resuscitation and stabilisation improve due to application of the advanced paediatric life support (APLS) principles, fewer children will require intubation when they are in extremis. Conversely, more children will require intubation as a planned urgent rather than emergent procedure. This will often be outside the first hour during stabilisation or prior to transfer to definitive care. Intubation may need to be carried out in the referring hospital prior to the arrival of a retrieval team and will require anaesthesia/sedation and muscle relaxation if the child is conscious. The technique used to secure the airway rapidly and safely in this situation is known as rapid sequence induction (RSI).


Rapid Sequence Induction


This has largely been the province of anaesthetists, for whom it is a core skill. However, it may also fall within the remit of paediatricians and emergency medicine specialists. Crucially, the person carrying out the procedure should be a confident, competent and experienced intubator. They should have at least one and ideally two skilled assistants and all the equipment available for intubation. In particular they should have the child on a tilting trolley or bed and have available a powerful, high-volume sucker. They must have a plan of action for a failed intubation. It is also appropriate for those clinicians who do not have the skills to perform RSI to learn about the technique so that they can provide support for those who undertake it.


The steps in rapid sequence induction are as follows:



1 Prepare as above.

2 Pre-oxygenate with 100% oxygen for at least 3 minutes.

3 Induce anaesthesia using a sedative or anaesthetic induction agent (see ‘Drugs’ below).

4 The safety and value of cricoid pressure during emergency intubation is not clear. Therefore the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation.

5 Administer a rapid-acting, short-lasting muscle relaxant, e.g. suxamethonium.

6 Check that intubation is successful in the usual way.

Drugs


It must be stressed that all sedative and anaesthetic drugs may cause cardiovascular collapse in the ill, particularly hypovolaemic, child. Drugs to support the failing circulation should be immediately to hand and the sedative/anaesthetic drugs should be given with extreme caution, often in very low doses. Anaesthetic induction agents that may be used are listed in Table 20.1.


Table 20.1 Anaesthetic induction agents for use in orotracheal intubation.



























Drug Dose Important notes
Ketamine 1–2 mg/kg Potent analgesia, dissociative anaesthesia and less hypotensive. May cause ICP to rise and should be used with caution in cases of head injury or high ICP
Propofol Dose in healthy child around 3 mg/kg, but 1–2 mg/kg may suffice in a sick child Most commonly used induction agent, therefore familiar. Very good intubating conditions, but much less cardiovascular system stability
Thiopental (thiopentole) Dose in healthy child around 5 mg/kg, but 1–2 mg may suffice in a sick child Historically the agent of choice. Very smooth onset, but may induce marked cardiovascular impairment
Sedative drugs Again, much lower doses may be needed in a sick child Benzodiazepines: midazolam is the most commonly used drug in this group
Opioid drugs
Fentanyl and morphine are commonly used

ICP, intracranial pressure.


Technique of Tracheal Intubation


The technique of tracheal intubation for immediate intubation in the apnoeic child or following RSI in the planned intubation is as follows:



1 Ensure that adequate ventilation and oxygenation by face mask are in progress. It is much less worrying for you and much safer for the child if adequate pre-oxygenation has been carried out. However, it should be realised that as one of the indications for intubation is failure to ensure adequate patency by any other means, this may not always be possible.

2 Prepare and check equipment (before inducing RSI if used under these circumstances).

3 Ensure manual immobilisation of the neck by an assistant if cervical spine injury is possible. Because of the relatively large occiput, it may be helpful to place a folded sheet or towel under the baby’s back and neck to allow extension of the head.

4 The laryngoscope should be held in the left hand and inserted initially into the right-hand side of the mouth, thereby displacing the tongue to the left.

  • In the infant, lift the epiglottis forward. The vocal cords should be sought in the midline directly underneath. It is easy to obscure the view by either looking too far to the left or too far to the right into either the piriform fossa or by inserting the blade too far past the larynx and down into the oesophagus. In circumstances where the laryngoscope blade has been inserted too far into the oesophagus, if the blade is cautiously and slowly withdrawn the vocal cords may suddenly pop into view.
  • In an unconscious baby being intubated by a relatively inexperienced doctor, it is often easiest to place the laryngoscope blade well beyond the epiglottis. The laryngoscope blade is placed down the right side of the tongue into the proximal oesophagus. With a careful lifting movement, the tissues are gently tented up to ‘seek the midline’. The blade is then slowly withdrawn until the vocal cords come into view. In some situations, it may be better to stay proximal to the epiglottis to minimise the risk of laryngospasm. This decision must be based on clinical judgement.
  • In the older child, visualise the epiglottis and place the tip of the laryngoscope anterior to it in the vallecula. The epiglottis is then pulled forwards by anterior pressure in the vallecula as demonstrated in Figure 20.2. Gently but firmly lift the handle towards the ceiling on the far side of the room, while being careful not to lever on the teeth (Figure 20.3).

5 The tube should then be inserted through the cords, with due attention to the fact that in small children the trachea is very short. Whilst it is important not to insert the tube too far, thereby avoiding inadvertent bronchial intubation, it is much, much more dangerous to have a tube which is too short as this may be displaced any time by movement of the child’s head.

6 Following the placement of the tracheal tube in the trachea its position must be verified by:

  • Observing bilateral and symmetrical movement of the chest.
  • Auscultation of the chest and abdomen.
  • Monitoring expired carbon dioxide in the exhaled air by either colour change capnometry or end-tidal capnography. This is the definitive test for tracheal tube placement.

7 If intubation is not achieved within 30 seconds, discontinue the attempt, re-establish pre-oxygenation and try again.

8 Inflate the cuff if present to provide an adequate seal. Note, however, that cuffed tubes should only be used in infants and small children by those who are trained and experienced in their use.
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on 20 Practical procedures: airway and breathing

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