Emergent Airway Management
When a child presents in respiratory distress secondary to stridor, the primary role of the emergency clinician is airway management. The team should always be prepared for the worst-case scenario and have all necessary team members present.32 If there is suspicion for a difficult intubation or the need for a surgical airway, otolaryngology (ear, nose, and throat [ENT]) and anesthesiology consultants should be contacted as soon as possible. If these resources are not available, transferring the patient to a tertiary care center should be considered. If a surgical airway is being considered, an operating room should be secured.56 Endotracheal tube (ETT) size should be considered carefully, as children with acute-onset stridor may have swelling, requiring a smaller ETT size than expected. Upon arrival, all team members should make an effort to keep the patient and family calm. The child should be allowed to maintain a position of comfort to prevent airway compromise until a more permanent airway can be obtained.
When available and needed, induction with nitric oxide and halogenated gases (eg, halothane, isoflurane, and sevoflurane) is often the best method to relax the patient prior to intravenous line placement or placing the child supine to prepare for intubation.32 Sedative agents that have a higher risk for causing laryngospasm (eg, ketamine) should be avoided unless the emergency clinicians are prepared to intubate. In older, cooperative patients, awake fiberoptic intubation may be an option.32,57 In this rare event, awake intubation should be undertaken by experienced clinicians after local airway anesthesia has been provided.
To continue reading, please log in or purchase access.