Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques

Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting

BACKGROUND

Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician.

DISCUSSION

Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered.

CONCLUSIONS

An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.

Tracheobronchial intubation using flexible bronchoscopy in children with Pierre Robin sequence: Nursing considerations for complications

BACKGROUND

It has been shown that children with Pierre Robin sequence (PRS) have a higher risk of difficult intubation before surgery. When mask ventilation or tracheobronchial intubation is expected to be challenging, flexible bronchoscopy (FB) is advantageous in airway safety when it is used to guide tracheobronchial intubation (TI).

AIM

To evaluate the complications of TI using FB in children with PRS and explore the effect of nursing services on postoperative complications.

METHODS

One hundred and five children with PRS underwent TI using FB before early mandibular distraction osteogenesis. One hundred and eight children with common pneumonia who did not have a difficult airway were set as the control group. Demographic data, success rates of TI, time required for TI, number of TI attempts, and the incidence of postoperative complications were assessed. Besides, the strategies used to attenuate complications were investigated.

RESULTS

The success rate of TI was 100% in children with PRS, while the success rate at the first attempt in the PRS group was significantly lower than that in the control group (88.6% vs 98.2%, P = 0.005). The time required for TI in the PRS group was markedly longer than that in the control group (P < 0.001). Children in the PRS group required repetitive operations to enter the glottis successfully (P = 0.017). The incidence of complications was noticeably higher in the PRS group (50/105, 47.6%) than in the control group (36/108, 33.3%) (P = 0.034). Seven of 105 PRS children experienced laryngeal edema (LE) (6.7%), compared with one (0.9%) in the control group (P = 0.034). Out of the seven patients who had LE, all were reintubated and managed with steroids: six recovered with inhaled steroids alone before extubated, and one was given systemic corticosteroids before recovery.

CONCLUSION

FB contributes to a high success rate of TI in children with PRS. To prevent LE, operators should pay more attention to catheter material, catheter lubrication and intubation time.

Ultra-slim flexible bronchoscopy-guided topical hemostatic drugs administration for the management of life-threatening refractory pulmonary hemorrhage in a preterm infant: Case report

Pulmonary hemorrhage (PH) is a rare acute catastrophic event with high mortality among neonates, especially preterm infants. Primary treatments included pulmonary surfactant, high-frequency oscillatory ventilation, epinephrine, coagulopathy management, and intermittent positive pressure ventilation. However, there are still challenges in diagnosing and treating refractory or focal pulmonary hemorrhages. Ultra-slim bronchoscopy has been widely used in the field of critically ill children and is increasingly being done in neonates with critical respiratory disease in recent years. In this study, we report a case with refractory pulmonary hemorrhage in premature infants, which was finally diagnosed as localized hemorrhage in the upper left lobe and cured by ultra-slim bronchoscopy-guided topical hemostatic drug administration. Bronchoscopy is an optional, safe, and practicable technique for early diagnosis and direct injection therapy of neonatal PH in managing life-threatening PH.

Adjunct Devices for the Pediatric Difficult Airway: A Case Report

This is a case report of a pediatric patient with a difficult airway, in which several airway adjuncts were used simultaneously to successfully provide adequate oxygenation and ventilation during cardiac arrest. Difficult airways are low-incidence, high-risk emergencies in children, and airway adjuncts may be used infrequently, let alone in combination. Included in the discussion of this case are a description of each airway adjunct and a discussion of the process needed to incorporate airway adjuncts safely and effectively into patient care.

Emergency intubation of children outside of the operating room

Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.

Effectiveness of tip rotation in fibreoptic bronchoscopy under different experimental conditions: an in vitro crossover study

Background

Proper manipulation of fibreoptic bronchoscopes is essential for successful tracheal intubation or diagnostic bronchoscopy. Failure of proper navigation and rotation of the fibrescope may lead to difficulties in advancing the fibrescope and might also be responsible for (unnecessary) difficulties and delays in fibreoptic tracheal intubation, with subsequent hypoxaemia. The present study, therefore, aimed to assess the effectiveness of tip rotation in flexible bronchoscopes in different experimental conditions.

Methods

Five differently sized pairs of fibrescopes (outer diameters of 2.2, 2.4, 3.5, 4.2, and 5.2 mm) were inserted into paediatric airway manikins via an appropriately sized laryngeal mask and were turned clockwise or anticlockwise at the fibrescope body or cord to 45, 90, and 180°, with the cord held either straight or bent. The primary outcome measure was the ratio of rotation measured at the tip over the rotation performed with the fibrescope body or cord.

Results

Overall, the 'body' turn was significantly less effective when a bent cord was present (mean difference ranging from 29.8% (95% confidence interval 8.8-50.9) to 117.4% (93.6-141.2). This difference was diminished when the 'cord' turn was performed. Smaller fibrescopes, with outer diameters of 2.2 and 2.4 mm, were inferior with respect to the transmission of 'body' rotation to the tip.

Conclusions

'Cord' turning of the fibrescope appears to be more effective in rotating the tip than a turn of the fibrescope 'body' only. Straightening the fibrescope cord and combined 'body' and 'cord' turning are recommended.

A quality improvement initiative to increase the safety of pediatric emergency airway management

BACKGROUND

Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable.

AIMS

The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension.

METHODS

This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored.

RESULTS

Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified.

CONCLUSION

Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.