Alternative airway devices for use in children requiring prehospital airway management: update and case discussion

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Children with Limited Oral Opening Can Be Safely Managed without a Tracheostomy

Objective

To describe airway management of children with limited oral opening that does not allow for routine orotracheal intubation by direct laryngoscopy. To analyze the incidence and outcome of airway compromise or loss in patients without a tracheostomy in place.

Study Design

Case series with chart review.

Setting

Tertiary children’s hospital.

Subjects

Children with limited oral opening that does not allow for routine orotracheal intubation.

Methods

Children treated at Children’s Hospitals and Clinics of Minnesota from 1997 to 2012 with severe trismus were identified and included in the study. Hospital and clinic records were reviewed.

Results

Ten children (mean age, 13 years; range, 7-17 years) were identified for inclusion into the study. A total of 109 operations requiring general anesthesia (average of 10.9 per patient; range, 0-23) were performed on patients without a tracheostomy in place. Flexible fiber-optic nasotracheal intubation was performed in 58 cases. The remainder of airway control was by mask ventilation (33 cases), various methods of orotracheal intubation (10 cases), unknown (6 cases), and laryngeal mask airway (2 cases). There was a total of 118 patient-years of follow-up without a tracheostomy tube in place (average of 11.8 years per patient). During this period, there were no episodes of acute airway compromise that resulted in neurologic deficits.

Conclusion

Children with limited oral opening that does not allow for routine orotracheal intubation with direct laryngoscopy may be safely managed without a tracheostomy, even when the child requires frequent procedures under general anesthesia.

Longitudinal and regional trends in paramedic student exposure to advanced airway placement: 2001-2011

OBJECTIVES

The primary aims of this study were to determine whether the frequency of placement, type of advanced airway, and settings of advanced airway placement (clinical vs. field) have changed for paramedic students over the last 11 years, and to describe regional differences regarding the same set of variables.

METHODS

This study was a retrospective review of prospectively reported airway procedures documented by paramedic students in Fisdap ( http://www.fisdap.net ). Students were included if they graduated from a paramedic program, had procedure entries verified by a preceptor, and provided consent for research. Exclusion criteria included students who had a total number of airway placements ≥2 standard deviations from the mean or had 0 airway placements recorded, and programs with <10 graduating students total over the study period. Airway device types and educational settings were descriptively compared over the 11-year study period by year and region.

RESULTS

A total of 8,934 paramedic student records were reviewed, with 2,811 excluded based on a priori criteria, leaving 6,123 records for analysis. In each year, the median number of airway devices placed per student was greater in the clinical setting. Endotracheal intubation (ETI) was more common than alternative airway placement in both the field and clinical settings. The median number of clinical ETIs per student has remained relatively constant at 7. The median number of field ETIs per student ranged from 0 to 1 over the study period, with a median alternative airway placement rate of 0 for both clinical and field settings. For all regions, the majority of procedures were performed in a clinical environment. The median number of clinical alternative airway device placements was 0 for all regions. The number of clinical ETIs ranged from 5 to 11 per student, with the highest number of ETIs per student in the West North Central and New England regions and the lowest in the West South Central and East South Central regions.

CONCLUSION

Paramedic students gain the majority of their advanced airway experience in the clinical setting. ETI remains more common than alternative airway placement, although there is significant geographic variation in the number of ETIs per student. High rates of clinical intubations do not correlate with high rates of field intubations.

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.

Prehospital pediatric King LT-D use: a pilot study

OBJECTIVE

To determine whether prehospital providers can successfully place a pediatric King laryngeal tube (LT-D) and ventilate a Laerdal SimBaby pediatric simulator during a respiratory arrest simulation.

METHODS

We studied the ability of 45 paramedics and flight nurses to place the pediatric King LT-D in a SimBaby manikin. For the purposes of this study, paramedics and flight nurses were considered equivalent, because in this air medical system they have the same scope of practice in regard to airway skills. Because the participants had previous training and field experience with the adult King LT-D, we limited pediatric King LT-D training to our standard adult training plus selecting the correct size and inflation volumes for the device. Outcomes included rate of successful pediatric King LT-D placement, number of attempts to correctly place the tube, and time to first adequate ventilation. The subjects were evaluated on airway management using an 11-point skill test. A score of 8 or greater (≥ 73%) was considered passing. The subjects indicated their perceptions and preferences for the pediatric King LT-D using a five-point Likert scale. Data were analyzed using descriptive statistics.

RESULTS

Crew members successfully placed the pediatric King LT-D 95.5% (43/45) of the time. The median number of attempts was one. Four subjects required a second attempt; two of these subjects failed at placement. Mean time to placement was 34 seconds (95% confidence interval [CI]: 26.4-67.3 sec). Ninety percent of the participants (40/45) successfully completed the skill test, with a mean score of 78.2% (95% CI: 73.6-82.7). The subjects strongly agreed that their previous training on the adult King LT-D and using it in the field had adequately prepared them to use the pediatric King LT-D. The subjects agreed that the pediatric King LT-D was easier to place than a pediatric endotracheal tube; they strongly agreed that they would use the pediatric King LT-D as an alternative airway. The participants disagreed that they would prefer the pediatric King LT-D as a primary means of securing pediatric airways.

CONCLUSIONS

The pediatric King LT-D was quickly and reliably placed. Providers perceived the pediatric King LT-D to be easier to use than pediatric endotracheal intubation in this setting.

A practical approach to paediatric emergencies in the radiology department

Acute life-threatening events involving children in the radiology department are rare. Nonetheless, radiologists should be competent in the relatively simple procedures required to maintain or restore vital functions in paediatric patients, particularly if their practice involves seriously ill or sedated children. This article gives a practical overview of the immediate management of paediatric emergencies that the radiologist is likely to encounter, using a structured (ABCD) approach. Emphasis is given to the early recognition of respiratory embarrassment and shock, and early intervention to prevent deterioration towards circulatory arrest. The management of cardiorespiratory arrest, anaphylaxis and convulsions in children is also addressed.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.