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Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
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2
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Stein ML, Sarmiento Argüello LA, Staffa SJ, Heunis J, Egbuta C, Flynn SG, Khan SA, Sabato S, Taicher BM, Chiao F, Bosenberg A, Lee AC, Adams HD, von Ungern-Sternberg BS, Park RS, Peyton JM, Olomu PN, Hunyady AI, Garcia-Marcinkiewicz A, Fiadjoe JE, Kovatsis PG. Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine 2024; 69:102461. [PMID: 38374968 PMCID: PMC10875248 DOI: 10.1016/j.eclinm.2024.102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
Background The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding None.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Julia Heunis
- Department of Pediatrics, Boston Children’s Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chinyere Egbuta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen G. Flynn
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A. Khan
- Department of Anesthesiology, UTHealth - McGovern Medical School, Houston, TX, USA
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children’s Hospital, and Anaesthesia Research Group, Murdoch Children’s Research Institute, Parkville, Australia
| | - Brad M. Taicher
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, USA
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Angela C. Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H. Daniel Adams
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Britta S. von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children’s Hospital, Institute for Paediatric Perioperative Excellence, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perioperative Medicine Team, Perioperative Care Program, and Telethon Kids Institute, Perth, Australia
| | - Raymond S. Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - James M. Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick N. Olomu
- Department of Pediatric Anesthesiology and Pain Management, Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Agnes I. Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E. Fiadjoe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
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Fuchs A, Koepp G, Huber M, Aebli J, Afshari A, Bonfiglio R, Greif R, Lusardi AC, Romero CS, von Gernler M, Disma N, Riva T. Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis. Br J Anaesth 2024; 132:392-406. [PMID: 38030551 DOI: 10.1016/j.bja.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children. METHODS This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation. RESULTS After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration. CONCLUSION This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range. CLINICAL TRIAL REGISTRATION Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Gabriela Koepp
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Aebli
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Arash Afshari
- Department of Paediatric And Obstetric Anesthesia, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Institute of Clinical Medicine, Copenhagen, Denmark
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria; University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina S Romero
- Anesthesia, Critical Care and Pain Department, Hospital General Universitario De Valencia, Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | | | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Lima LC, Cumino DDO, Vieira AM, Silva CHRD, Neville MFL, Marques FO, Quintão VC, Carlos RV, Fujita ACG, Barros HÍM, Garcia DB, Ferreira CBT, Barros GAMD, Módolo NSP. Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744478. [PMID: 38147975 PMCID: PMC10877349 DOI: 10.1016/j.bjane.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.
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Affiliation(s)
- Luciana Cavalcanti Lima
- Instituto Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Faculdade Pernambucana de Saúde, Recife, PE, Brazil
| | - Débora de Oliveira Cumino
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Mariana Fontes Lima Neville
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Anestesiologia, Dor e Terapia Intensiva, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil
| | | | - Vinicius Caldeira Quintão
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brazil
| | - Ricardo Vieira Carlos
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Ana Carla Giosa Fujita
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | - Hugo Ítalo Melo Barros
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Serviço de Anestesiologia Pediátrica/SAPE, Brazil; Hospital Municipal Menino Jesus, São Paulo, SP, Brazil
| | | | | | - Guilherme Antonio Moreira de Barros
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil.
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6
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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7
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Soong C, Lee YS, Lin CH, Chen CH, Soong WJ. Sustained pharyngeal inflation in infant airway-Flexible bronchoscopy measurements. PLoS One 2023; 18:e0294029. [PMID: 37992011 PMCID: PMC10664907 DOI: 10.1371/journal.pone.0294029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/22/2023] [Indexed: 11/24/2023] Open
Abstract
Sustained pharyngeal inflation (SPI) with pharyngeal oxygen flow and nasal closure (PhO2-NC) technique create positive inflation pressure in the airway. This study measured the peak inflation pressure (PIP) levels and image changes with SPI-assisted flexible bronchoscopy (SPI-FB) and compared the effects in the pharyngeal space and mid-tracheal lumen. This prospective study enrolled 20 participants aged 6 months to 3 years. Each participant underwent sequential SPI-FB of four different durations (0, 1s, 3s, and 5s) for three cycles. We used a 3.8 mm OD flexible bronchoscope to measure and analyze PIP levels, images, and lumen dimension scores. A total of 480 data were collected. The mean (SD) age and body weight were 12.0 (11.5) months and 7.8 (7.5) kg, respectively. The mean (IQR) PIPs were 4.2 (2.0), 18.5 (6.1), 30.6 (13.5), and 46.1 (25.0) cmH2O in the pharynx and 5.0 (1.6), 17.5 (6.5), 28.0 (12.3), 46.0 (28.5) cmH2O in the mid-trachea at SPI durations of 0, 1s, 3s, and 5s, respectively. The PIP levels had a positive correlation (p <0.001) with different SPI durations in both pharynx and trachea, and were nearly identical (p = 0.695, 0.787, and 0.725 at 1s, 3s, and 5s, respectively) at the same duration except the 0 s (p = 0.015). Lumen dimension scores also significantly increased with increasing SPI durations (p <0.05) in both locations. The identified lesions significantly increased as PIP levels increased (p <0.001). Conclusion: SPI-FB using PhO2-NC with durations up to 3s is safe and informative technique that provides controllable PIP, dilates airway lumens, and benefits lesion detection in the pharyngeal space and mid-tracheal lumen.
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Affiliation(s)
- Christina Soong
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Sheng Lee
- Department of Pediatrics, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Heng Lin
- Division of Pediatric Pulmonology, Children’s Hospital, China Medical University, Taichung, Taiwan
| | - Chieh-Ho Chen
- Division of Pediatric Pulmonology, Children’s Hospital, China Medical University, Taichung, Taiwan
| | - Wen-Jue Soong
- Department of Pediatrics, School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Pediatric Pulmonology, Children’s Hospital, China Medical University, Taichung, Taiwan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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8
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Napolitano N, Polikoff L, Edwards L, Tarquinio KM, Nett S, Krawiec C, Kirby A, Salfity N, Tellez D, Krahn G, Breuer R, Parsons SJ, Page-Goertz C, Shults J, Nadkarni V, Nishisaki A. Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated events in critically ill children. Crit Care 2023; 27:26. [PMID: 36650568 PMCID: PMC9847056 DOI: 10.1186/s13054-023-04304-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/06/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. METHODS AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016-2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1-7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). RESULTS Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infants, those with a primary cardiac diagnosis or difficult airway features, and patient intubated due to respiratory or neurological failure or shock. Conversely, AO was used more often in TIs done for procedures and those assisted by video laryngoscopy. AO utilization was associated with a lower incidence of adverse TIAEs (AO 10.5% vs. without AO 13.5%, p < 0.001), aOR 0.75 (95% CI 0.58-0.98, p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72-1.12, p = 0.33 and the occurrence of hypoxemia was not different: AO 14.2% versus without AO 15.2%, p = 0.43. CONCLUSION While AO use was associated with a lower occurrence of adverse TIAEs in children who required TI in the pediatric ICU after accounting for site-level clustering, this result may be explained by differences in patient, provider, and practice factors. Trial Registration Trial not registered.
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Affiliation(s)
- Natalie Napolitano
- grid.239552.a0000 0001 0680 8770Respiratory Therapy Department, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Lee Polikoff
- grid.40263.330000 0004 1936 9094Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI USA
| | - Lauren Edwards
- grid.266813.80000 0001 0666 4105Division of Critical Care, Department of Pediatrics, Children’s Healthcare of Atlanta, University of Nebraska Medical Center and Children’s Hospital and Medical Center, Omaha, NE USA
| | - Keiko M. Tarquinio
- grid.189967.80000 0001 0941 6502Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA
| | - Sholeen Nett
- grid.413480.a0000 0004 0440 749XDivision of Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH USA
| | - Conrad Krawiec
- grid.29857.310000 0001 2097 4281Division of Pediatric Critical Care Medicine, Penn State Health Children’s Hospital, Hershey, PA USA
| | - Aileen Kirby
- grid.5288.70000 0000 9758 5690Division of Pediatric Critical Care Medicine, Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR USA
| | - Nina Salfity
- grid.417276.10000 0001 0381 0779Department of Critical Care, Phoenix Children’s Hospital, Phoenix, AZ USA
| | - David Tellez
- grid.417276.10000 0001 0381 0779Department of Critical Care, Phoenix Children’s Hospital, Phoenix, AZ USA
| | - Gordon Krahn
- grid.17091.3e0000 0001 2288 9830Division of Pediatric Critical Care, University of British Columbia, Vancouver, BC Canada
| | - Ryan Breuer
- grid.413993.50000 0000 9958 7286Division of Pediatric Critical Care, Oishei Children’s Hospital, Buffalo, NY USA
| | - Simon J. Parsons
- grid.413571.50000 0001 0684 7358Division of Critical Care, Alberta Children’s Hospital, Calgary, Canada
| | - Christopher Page-Goertz
- grid.413473.60000 0000 9013 1194Division of Critical Care Medicine, Akron Children’s Hospital, Akron, OH USA
| | - Justine Shults
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Vinay Nadkarni
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Akira Nishisaki
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
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9
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Nishida K, Watanabe F, Kojima T. Efficacy of in-situ simulation training using evaluation checklists for sudden oxygen supply failure during general anesthesia: A preliminary report. Saudi J Anaesth 2023; 17:1-6. [PMID: 37032690 PMCID: PMC10077802 DOI: 10.4103/sja.sja_541_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/05/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Sudden oxygen supply failure (OSF) is a life-threatening consequence that may be triggered by natural disasters. Anesthesiologists are required to manage OSF promptly in such catastrophic situations. However, the current evidence regarding the efficacy of anesthesia training for sudden OSF is insufficient. This preliminary study aimed to introduce our in-situ simulation training utilizing evaluation checklists for a sudden OSF situation during general anesthesia and to evaluate the efficacy of the training program for anesthesia providers. Methods This is a preliminary single-center, prospective study. We developed an OSF simulation scenario utilizing evaluation checklists with key actions to manage OSF. The training session comprised four components: orientation, benchmark evaluation (pre-test) according to the checklists, a short didactic lecture, and post-lecture evaluation (post-test). The scenario comprised two steps wherein the participants were supposed to utilize different oxygen supply sources immediately after OSF (Step 1) and minimize the amount of oxygen consumption (Step 2). Results Fifteen anesthesia providers were enrolled. The score for all anesthesia providers in the post-test was significantly higher than that in the pre-test (median 8 [IQR: 8, 8], 3 [IQR: 3, 4], P < 0.001, respectively). The successful performance rates of all anesthesia providers in one key action of all the four in Step 1 and four of all the six in Step 2 were significantly higher in the post-test than in the pre-test. Conclusions Our in-situ training method utilizing evaluation checklists for a sudden OSF situation improved overall performance of anesthesia providers.
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Affiliation(s)
- Keisuke Nishida
- Department of Anesthesiology, Aichi Children's Healthy and Medical Center, Obu-City, Aichi, Japan
| | - Fumio Watanabe
- Department of Anesthesiology, Aichi Children's Healthy and Medical Center, Obu-City, Aichi, Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Healthy and Medical Center, Obu-City, Aichi, Japan
- Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
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10
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Ali N, Sawyer T. Special consideration in neonatal resuscitation. Semin Perinatol 2022; 46:151626. [PMID: 35738945 DOI: 10.1016/j.semperi.2022.151626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.
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Affiliation(s)
- Noorjahan Ali
- Department of Pediatrics Division of Perinatal-Neonatal Medicine UT Southwestern of Dallas Children's Medical Center of Dallas Texas, USA.
| | - Taylor Sawyer
- Department of Pediatrics Division of Neonatology, University of Washington School of Medicine Seattle Washington, USA
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11
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Soong WJ, Tsao PC, Yang CF, Sung YH, Soong YH. Early detection of laryngeal cleft in infants by novel technique of flexible endoscopy with sustained pharyngeal inflation. Pediatr Pulmonol 2022; 57:2122-2127. [PMID: 35596199 DOI: 10.1002/ppul.25988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 04/07/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE We report a novel technique of flexible endoscopy with noninvasive ventilation (NIV) and sustained pharyngeal inflation (FE-NIV-SPI) in assessing aeroesophageal tracts (AET) to facilitate early detection of laryngeal clefts in infants. METHODS Medical charts and flexible endoscopy videos of the children who were diagnosed with laryngeal cleft in a tertiary care hospital between January 2000 and December 2020 were retrospectively reviewed and analyzed. The FE-NIV-SPI technique had been applied to all these children. RESULTS Totally, 12 infants with laryngeal cleft were identified. This equates to a prevalence of 0.28% in all the children who underwent flexible endoscopy at our institution. Their mean age was 5.0 ± 4.9 months and mean body weight was 4.7 ± 2.3 kg. Nine (75%) infants were referred in without laryngeal cleft diagnosis, which was missed by 11 prior bronchoscopy and 5 computer tomography examinations. With the FE-NIV-SPI technique, the pharyngolaryngeal space could be pneumatically dilated permitting a detailed assessment. All laryngeal cleft types and coexisting AET lesions were visualized at the first FE-NIV-SPI examination with a mean time of 4.2 ± 0.9 min; they were eight Type I, two Type II, and one Type III. Ten (83.3%) infants had coexisting airway malacia. CONCLUSION Routine use of FE-NIV-SPI technique can help in early detection of laryngeal clefts and other associated AET lesions. Further multicenter collaborative investigations are essential to verify the early detection of this rare and occult lesion of the laryngeal cleft with this technique.
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Affiliation(s)
- Wen-Jue Soong
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pei-Chen Tsao
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Feng Yang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hung Sung
- Department of Medical Education, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hui Soong
- Pulmonary and Critical Care, Paloma Medical Group, Los Angles , California, USA
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12
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Pal N, Karuppiah A, Butterworth J. Nasal High-Flow Therapy during Neonatal Endotracheal Intubation. N Engl J Med 2022; 387:382. [PMID: 35939593 DOI: 10.1056/nejmc2207316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nirvik Pal
- Virginia Commonwealth University, Richmond, VA
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13
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Aroonpruksakul N, Sangsungnern P, Kiatchai T. Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial. Transl Pediatr 2022; 11:427-437. [PMID: 35558969 PMCID: PMC9085956 DOI: 10.21037/tp-21-484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction. METHODS This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO2) ≤92%. RESULTS Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO2 was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069). CONCLUSIONS In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20210802002.
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Affiliation(s)
- Naiyana Aroonpruksakul
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerapong Sangsungnern
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Taniga Kiatchai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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Johansen M, Veyckemans F, Engelhardt T. Congenital anomalies of the large intrathoracic airways. Paediatr Anaesth 2022; 32:126-137. [PMID: 34797930 DOI: 10.1111/pan.14339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/03/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022]
Abstract
Congenital lung lesions are numerous but rare in individual clinical practice. They do require close multidisciplinary collaboration between health care professionals. This educational review will focus on the pathophysiology, clinical manifestations, surgical approaches, and anesthetic management of congenital anomalies of the large intrathoracic airways: congenital tracheal stenosis, tracheal agenesis, tracheal diverticulum, bronchial anomalies (tracheal, esophageal, or bridging bronchus), congenital lung malformations, lung sequestrations and Scimitar syndrome, lobar emphysema, Williams-Campbell syndrome, and pleuropulmonary blastoma. In addition, this review will illustrate common pitfalls and challenges related to the anesthesia management with emphasis on ventilation and correct endotracheal tube positioning.
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Affiliation(s)
- Mathias Johansen
- Department of Paediatric Anaesthesiology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Francis Veyckemans
- Clinique d'Anesthésie Pédiatrique, Hôpital Jeanne de Flandre, CHU de Lille, Lille, France
| | - Thomas Engelhardt
- Department of Paediatric Anaesthesiology, Montreal Children's Hospital, Montreal, Quebec, Canada
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15
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Soong WJ, Tsao PC, Yang CF, Lee YS, Lin CH, Chen CH. Flexible Endoscopy With Non-invasive Ventilation Enables Clinicians to Assess and Manage Infants With Severe Bronchopulmonary Dysplasia. Front Pediatr 2022; 10:837329. [PMID: 35515350 PMCID: PMC9062875 DOI: 10.3389/fped.2022.837329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The objectives of the study were to determine the efficacy of flexible endoscopy (FE) to assess the approachable aeroesophageal tract (AET) and subsequent changes in clinical management in infants with severe bronchopulmonary dysplasia (sBPD). METHODS This retrospective study investigated sBPD infants who received FE measurement from 2011 to 2020. FE was supported with non-invasive ventilation (FE-NIV) of pharyngeal oxygen with nose closure and abdominal compression without any mask or laryngeal mask airway. Data on AET lesions, changes in subsequent management, and FE therapeutic interventions were collected and analyzed. RESULTS Forty-two infants were enrolled in the study. Two thin scopes (1.8- and 2.6-mm outer diameter) were used. FE analysis revealed 129 AET lesions in 38 (90.5%) infants. Twenty-eight infants (66.7%) had more than one lesion. Thirty-five (83.3%) infants had 111 airway lesions where bronchial granulations (28, 25.2%), tracheomalacia (18, 16.2%), and bronchomalacia (15, 13.5%) were the main complications. Eighteen esophageal lesions were found in 15 (35.7%) infants. No significant FE-NIV complications were observed. The FE findings resulted in changes in management in all 38 infants. Thirty-six (85.7%) infants underwent altered respiratory care with pressure titrations (29, 45.3%), shortened suction depth (17, 26.6%), immediate extubation (8, 12.5%), changed insertion depth of endotracheal tube (7, 10.9%) and tracheostomy tube (3, 4.7%). Twenty-one (50%) infants had 50 pharmacotherapy changes, including added steroids, anti-reflux medicine, antibiotics, and stopped antibiotics. Eighteen (42.8%) infants received 37 therapeutic FE-NIV procedures, including 14 balloon dilatations, 13 laser-plasty, and 10 stent implantations. Seven (16.7%) infants underwent surgeries for four tracheostomies and three fundoplications. CONCLUSION Flexible endoscopy with this non-invasive ventilation could be a safe and valuable technique for direct and dynamic visual measurement of AET, which is essential for subsequent medical decision making and management in infants with sBPD.
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Affiliation(s)
- Wen-Jue Soong
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung City, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei City, Taiwan.,Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Pei-Chen Tsao
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei City, Taiwan.,Department of Pediatrics, School of Medicine, National Yang-Ming Chiao Tung University, Taipei City, Taiwan
| | - Chia-Feng Yang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei City, Taiwan.,Department of Pediatrics, School of Medicine, National Yang-Ming Chiao Tung University, Taipei City, Taiwan
| | - Yu-Sheng Lee
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei City, Taiwan.,Department of Pediatrics, School of Medicine, National Yang-Ming Chiao Tung University, Taipei City, Taiwan
| | - Chien-Heng Lin
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung City, Taiwan
| | - Chieh-Ho Chen
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung City, Taiwan
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16
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George S, Wilson M, Humphreys S, Gibbons K, Long E, Schibler A. Apnoeic oxygenation during paediatric intubation: A systematic review. Front Pediatr 2022; 10:918148. [PMID: 36479287 PMCID: PMC9720125 DOI: 10.3389/fped.2022.918148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This review assesses the effect of apnoeic oxygenation during paediatric intubation on rates of hypoxaemia, successful intubation on the first attempt and other adverse events. DATA SOURCES The databases searched included PubMed, Medline, CINAHL, EMBASE and The Cochrane Library. An electronic search for unpublished studies was also performed. STUDY SELECTION We screened studies that include children undergoing intubation, studies that evaluate the use of apnoeic oxygenation by any method or device with outcomes of hypoxaemia, intubation outcome and adverse events were eligible for inclusion. DATA EXTRACTION Screening, risk of bias, quality of evidence and data extraction was performed by two independent reviewers, with conflicts resolved by a third reviewer where consensus could not be reached. DATA SYNTHESIS From 362 screened studies, fourteen studies (N = 2442) met the eligibility criteria. Randomised controlled trials (N = 482) and studies performed in the operating theatre (N = 835) favoured the use of apnoeic oxygenation with a reduced incidence of hypoxaemia (RR: 0.34, 95% CI: 0.24 to 0.47, p < 0.001, I 2 = 0% and RR: 0.27, 95% CI: 0.11 to 0.68, p = 0.005, I 2 = 68% respectively). Studies in the ED and PICU were of lower methodological quality, displaying heterogeneity in their results and were unsuitable for meta-analysis. Among the studies reporting first attempt intubation success, there were inconsistent effects reported and data were not suitable for meta-analysis. CONCLUSION There is a growing body of evidence to support the use of apnoeic oxygenation during the intubation of children. Further research is required to determine optimal flow rates and delivery technique. The use of humidified high-flow oxygen shows promise as an effective technique based on data in the operating theatre, however its efficacy has not been shown to be superior to low flow oxygen in either the elective anesthetic or emergency intubation situations Systematic Review Registration: This review was prospectively registered in the PROSPERO international register of systematic reviews (Reference: CRD42020170884, registered April 28, 2020).
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia.,School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Megan Wilson
- Emergency Department, Tweed Heads Hospital, Tweed Heads, NSW, Australia.,Emergency Department, Lismore Base Hospital, Lismore, NSW, Australia
| | - Susan Humphreys
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia.,Clinical Sciences, Murdoch Children's Research Institute, VIC, Australia.,Department of Critical Care, University of Melbourne, VIC, Australia
| | - Andreas Schibler
- Critical Care Research Group, Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia.,Wesley Medical Research, Auchenflower, QLD, Australia
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17
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Soong WJ, Chen CH, Lin CH, Yang CF, Lee YS, Tsao PC, Sung YH, Dhochak N. Sustained pharyngeal inflation on upper airway effects in children-Flexible bronchoscopy measurement. Pediatr Pulmonol 2021; 56:3293-3300. [PMID: 34407326 DOI: 10.1002/ppul.25608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/12/2021] [Accepted: 07/20/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Sustained pharyngeal inflation (SPI) with pharyngeal oxygen and nose-closure (PhO2 -NC) can create positive peak inflation pressure (PIP) inside the pharyngolaryngeal space (PLS). This study measured and compared the effects of four different SPI durations in the PLS. METHODS A prospective study, 20 consecutive children aged between 6 months and 3 years old, scheduled for elective flexible bronchoscopy (FB) suspected positive PLS findings were enrolled. SPI was performed twice in four different durations (0, 1, 3, and 5 s) sequentially in each infant. PIP was measured for each SPI in the pharynx, while simultaneously record images at two locations of the oropharynx and supra-larynx. Patient demographic details, PIP levels, lumen expansion scores, and images of PLS were measured and analyzed. RESULTS Twenty patients with 40 measurements were collected. The mean (SD) age and weight were 11.6 (9.1) months and 6.8 (2.4) kg, respectively. The measured mean (SD) pharyngeal PIPs were 4.1 (3.3), 21.9 (7.0), 42.2 (12.3), and 65.5 (18.5) cmH2 O at SPI duration of 0, 1, 3, and 5 s, respectively, indicating significant (p<.001) positive correlation. At assigned locations, corresponding PLS images also displayed a significant increase in lumen expansion scores and a number of detected lesions with an increase in SPI duration (p < .004). The mean (SD) procedural time was 5.7 (1.2) min. No study-related complication was noted. CONCLUSIONS FB utilizing PhO2 -NC as SPI of 1-3 s is a simple, less invasive, and valuable ventilation modality. It provides an adequate PIP level to expand the PLS and improve FB performance in children.
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Affiliation(s)
- Wen-Jue Soong
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chieh-Ho Chen
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chien-Heng Lin
- Division of Pediatric Pulmonology, Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chia-Fang Yang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Sheng Lee
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pei-Chen Tsao
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hung Sung
- Department of Medical Education, MacKay Memorial Hospital, Taipei, Taiwan
| | - Nitin Dhochak
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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18
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Bruckner M, Morris NM, Pichler G, Wolfsberger CH, Heschl S, Mileder LP, Schwaberger B, Schmölzer GM, Urlesberger B. In Newborn Infants a New Intubation Method May Reduce the Number of Intubation Attempts: A Randomized Pilot Study. CHILDREN (BASEL, SWITZERLAND) 2021; 8:553. [PMID: 34206746 PMCID: PMC8307684 DOI: 10.3390/children8070553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/27/2021] [Accepted: 06/24/2021] [Indexed: 11/19/2022]
Abstract
Severe desaturation or bradycardia often occur during neonatal endotracheal intubation. Using continuous gas flow through the endotracheal tube might reduce the incidence of these events. We hypothesized that continuous gas flow through the endotracheal tube during nasotracheal intubation compared to standard nasotracheal intubation will reduce the number of intubation attempts in newborn infants. In a randomized controlled pilot study, neonates were either intubated with continuous gas flow through the endotracheal tube during intubation (intervention group) or no gas flow during intubation (control group). Recruitment was stopped early due to financial and organizational issues. A total of 16 infants and 39 intubation attempts were analyzed. The median (interquartile range) number of intubation attempts and number of abandoned intubations due to desaturation and/or bradycardia were 1 (1-2) and 4 (2-5), (p = 0.056) and n = 3 versus n = 20, (p = 0.060) in the intervention group and control group, respectively. Continuous gas flow through the endotracheal tube during intubation seems to be favorable and there are no major unexpected adverse consequences of attempting this methodology.
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Affiliation(s)
- Marlies Bruckner
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
| | - Nicholas M. Morris
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
- Research Unit for Neonatal Macro- and Microcirculation, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria
| | - Christina H. Wolfsberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Pediatric Anesthesia, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria;
| | - Lukas P. Mileder
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB T5H 3V9, Canada;
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9, Canada
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria; (N.M.M.); (G.P.); (C.H.W.); (L.P.M.); (B.S.); (B.U.)
- Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria
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19
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Abstract
PURPOSE OF REVIEW Children are at risk of severe hypoxemia in the perioperative period owing to their unique anatomy and physiology. Safe and effective airway management strategies are therefore key to the practice of pediatric anesthesia. The goal of this review is to highlight recent publications (2019-2021) aimed to advance pediatric airway safety and to highlight a proposed simple, pediatric-specific, universal framework to guide clinical practice. RECENT FINDINGS Recent investigations demonstrate that infants with normal and difficult airways experience high incidences of multiple laryngoscopy attempts and resulting hypoxemia. Video laryngoscopy may improve tracheal intubation first attempt success rate in infants with normal airways. In infants with difficult airways, standard blade video laryngoscopy is associated with higher first attempt success rates over non-standard blade video laryngoscopy. Recent studies in children with Pierre Robin sequence and mucopolysaccharidoses help guide airway equipment and technique selection. Department airway leads and hospital difficult airway services are necessary to disseminate knowledge, lead quality improvement initiatives, and promote evidence-based practice guidelines. SUMMARY Pediatric airway management morbidity is a common problem in pediatric anesthesia. Improvements in individual practitioner preparation and management strategies as well as systems-based policies are required. A simple, pediatric-specific, universal airway management framework can be adopted for safe pediatric anesthesia practice.
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20
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Ayanmanesh F, Abdat R, Jurine A, Azale M, Rousseaux G, Coulons S, Samain E, Brasher C, Julien-Marsollier F, Dahmani S. Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children. Anaesth Crit Care Pain Med 2021; 40:100817. [PMID: 33677095 DOI: 10.1016/j.accpm.2021.100817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 10/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). METHODS In this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year). RESULTS Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). CONCLUSIONS Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.
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Affiliation(s)
- Fanny Ayanmanesh
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Rachida Abdat
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Amélie Jurine
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Mehdi Azale
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Guillaume Rousseaux
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Sarah Coulons
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Emmanuel Samain
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia; Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Florence Julien-Marsollier
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Souhayl Dahmani
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France.
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21
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Nishisaki A, Lee A, Li S, Sanders RC, Brown CA, Rehder KJ, Napolitano N, Montgomery VL, Adu-Darko M, Bysani GK, Harwayne-Gidansky I, Howell JD, Nett S, Orioles A, Pinto M, Shenoi A, Tellez D, Kelly SP, Register M, Tarquinio K, Simon D, Krawiec C, Shults J, Nadkarni V. Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators. Crit Care Med 2021; 49:250-260. [PMID: 33177363 DOI: 10.1097/ccm.0000000000004725] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN Multicenter time-series study. SETTING PICUs in the United States. PATIENTS All patients received tracheal intubations in ICUs. INTERVENTIONS We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.
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Affiliation(s)
- Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anthony Lee
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kyle J Rehder
- Division of Pediatric Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vicki L Montgomery
- Division of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY
| | - Michelle Adu-Darko
- Division of Critical Care, Children's Hospital of the University of Virginia, Charlottesville, VA
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Pediatric Acute Care Associates of North Texas PLLC, Medical City Children's Hospital, Dallas, TX
| | | | - Joy D Howell
- Department of Pediatrics, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Sholeen Nett
- Division of Pediatric Critical Care, Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Alberto Orioles
- Division of Critical Care, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
| | - Matthew Pinto
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Asha Shenoi
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Serena P Kelly
- Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR
| | - Melinda Register
- Department of Respiratory Therapy, Children's Healthcare of Atlanta, Atlanta, GA
| | - Keiko Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta GA
| | - Dennis Simon
- Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA
| | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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22
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Heninger J, Phillips M, Huang A, Jagannathan N. Management of the Difficult Pediatric Airway. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00408-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Soong WJ, Yang CF, Lee YS, Tsao PJ, Lin CH, Chen CH. Vallecular cyst with coexisting laryngomalacia: Successful diagnosis and laser therapy by flexible endoscopy with a novel noninvasive ventilation support in infants. Pediatr Pulmonol 2020; 55:1750-1756. [PMID: 32343051 DOI: 10.1002/ppul.24796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/09/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Vallecular cyst coexisting with laryngomalacia (VC-LM) can cause significant pharyngolaryngeal obstruction. Traditionally, it is diagnosed with flexible endoscopy (FE) and treated by rigid endoscopy. This study evaluates the effectiveness of solely using FE with novel noninvasive ventilation (NIV) of sustained pharyngeal inflation (SPI) support for both diagnosis and treatment in such infants. METHODS A retrospective review of consecutive infants who were diagnosed and treated for VC-LM in the 12-year period, 2007 to 2018, was conducted. Clinical variables, techniques, and outcomes were analyzed and reported. RESULTS Eighteen infants (10 males) were included. The mean age was 3.0 ± 0.6 months and the mean body weight was 4.6 ± 1.3 kg. Before FE, 14 infants were supported with bi-nasal prongs NIV (BN-NIV) and four infants with tracheal intubation. During diagnostic and therapeutic FE, all infants supported with a nasopharyngeal NIV (NP-NIV) only. All diagnoses were made in the first FE inspection of 3.5 ± 1.2 minutes. Thirteen lesions were immediately treated with FE laser therapy in 18.1 ± 1.7 minutes in the same FE course. Total FE time was 24.6 ± 2.8 minutes. Three infants needed revision laser therapy 4 days later. There was no desaturation (<90%), bradycardia (<100/min), or pneumothorax. After FE therapy, all infants were supported with BN-NIV only with significantly (<0.01) lower pressure and completely weaned off before being discharged 8.4 ± 1.5 days later. All infants, followed up for a 6-month period, showed many clinical improvements. CONCLUSIONS FE, with this NP-NIV and SPI supports, could offer accurate diagnosis and successful laser therapy of the VC-LM with procedural sedation in the same session in infants.
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Affiliation(s)
- Wen-Jue Soong
- Division of Pediatric Pulmonology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan
| | - Chia-Feng Yang
- Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Sheng Lee
- Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Jeng Tsao
- Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Heng Lin
- Division of Pediatric Pulmonology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chieh-Ho Chen
- Division of Pediatric Pulmonology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
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24
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Lyons C, Callaghan M. Apnoeic oxygenation in paediatric anaesthesia: a narrative review. Anaesthesia 2020; 76:118-127. [PMID: 32592510 DOI: 10.1111/anae.15107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2020] [Indexed: 12/19/2022]
Abstract
Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.
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Affiliation(s)
- C Lyons
- Department of Anaesthesia, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - M Callaghan
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
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25
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Lin EE, Nelson O, Isserman RS, Henderson AA, Rintoul NE, Lioy J, Javia LR, Tran KM, Fiadjoe JE. Management of neonatal difficult airway emergencies in the delivery room. Paediatr Anaesth 2020; 30:544-551. [PMID: 32196824 DOI: 10.1111/pan.13859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 01/29/2023]
Abstract
Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches.
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Affiliation(s)
- Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alicia A Henderson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Janet Lioy
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luv R Javia
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kha M Tran
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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26
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Else SDN, Kovatsis PG. A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures. Anesth Analg 2020; 130:831-840. [DOI: 10.1213/ane.0000000000004403] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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27
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Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth 2020; 30:269-279. [PMID: 32022437 DOI: 10.1111/pan.13814] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 12/21/2022]
Abstract
Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Raymond S Park
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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