Evidence-Based Emergency Management Of The Pediatric Airway
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Evidence-Based Emergency Management Of The Pediatric Airway

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentation
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Prehospital Care
  6. Anatomic And Physiologic Considerations
    1. Anatomic Differences
      1. Occiput
      2. Tongue
      3. Neck
      4. Airway Size
    2. Mechanics Of Ventilation
      1. Physiologic Response
  7. Emergency Department Evaluation
    1. The Pediatric Assessment Triangle
      1. Overall Appearance
      2. Work Of Breathing
      3. Circulation To The Skin
    2. Complete Assessment
  8. Emergency Department Treatment
    1. Preparation
      1. Laryngoscopy Blade Choice
      2. Cuffed Versus Uncuffed Endotracheal Tubes
      3. Endotracheal Tube Size
      4. Video-Assisted And Optical Laryngoscopy
      5. Gum Elastic Bougie
    2. Preoxygenation
      1. Preoxygenation Position
      2. Preoxygenation Duration
      3. Preoxygenation Using A Nonrebreather Mask
      4. Preoxygenation Using Nasal And/Or Oral Airways
      5. Preoxygenation Using Positive Pressure Ventilation
    3. Prevention Of Complications
      1. Critical Oxygen Desaturation
      2. Peri-intubation Hypotension
      3. Bradycardia
      4. Severe Acidosis
      5. Vomiting/Aspiration
    4. Pretreatment
      1. Lidocaine
      2. Opiates
      3. Atropine
      4. Defasciculating Dose Of A Paralytic
      5. Nontraditional Pretreatment Agents
    5. Paralysis With Induction
      1. Induction
        • Etomidate
      2. Ketamine
      3. Propofol
      4. Benzodiazepines (Diazepam, Lorazepam, Midazolam)
      5. Barbiturates (Methohexitol, Thiopental)
      6. Choice Of Induction Agent
      7. Paralytics
      8. Succinylcholine
      9. Rocuronium
      10. Others Paralytics (Vecuronium, Pancuronium, Mivacuronium)
    6. Protection And Positioning
    7. Placement With Confirmation
    8. Postintubation Management
  9. Alternative Airway Techniques
    1. Supraglottic Airway Devices
    2. Fiberoptic Intubation
    3. Digital Intubation
    4. Cricothyrotomy
    5. Needle Cricothyrotomy
  10. Special Circumstances
    1. The Obese Pediatric Patient
    2. The Difficult Airway
  11. Disposition
  12. Summary
  13. Risk Management Pearls For Pediatric Airway Management
  14. Time- And Cost-Effective Strategies
  15. Case Conclusions
  16. Clinical Pathway For Managing The Pediatric Airway
  17. Clinical Pathway For The Difficult Airway
  18. Tables and Figures
    1. Table 1. Anatomical Differences In The Airway Of The Young Child
    2. Table 2. Tone, Interactiveness, Consolability, Look-Gaze, Speech-Cry Assessment
    3. Table 3. Airway Features
    4. Table 4. Normal Respiratory Rates
    5. Table 5. Skin Circulation Characteristics
    6. Table 6. Normal Heart Rates
    7. Table 7. The 8 Ps of Rapid Sequence Intubation
    8. Table 8. Suggested Equipment For Successful Rapid Sequence Intubation
    9. Table 9. Prevention Strategies For Potential Complications
    10. Table 10. Recommendations For Pretreatment Agents For Rapid Sequence Intubation
    11. Table 11. Preferred And Alternate Sedative Agents
    12. Table 12. Sample Of Recommended Larygeal-Mask Airway Sizes Based On Size-Weight
  19. References


Pediatric airway emergencies are rare, yet they are anxiety-provoking events that can occur in both pediatric and general emergency departments. Several novel concepts regarding preoxygenation during rapid sequence intubation, anticipation and prevention of intubation-related complications, the utility of premedication agents, and the selection of induction and paralytic agents have been highlighted in recent clinical trials and review articles. In this review, we analyze the data behind these concepts, highlight current pediatric literature related to these issues, and present reasonable conclusions based on the best available evidence. We begin with an analysis of the anatomic and physiologic differences commonly encountered in the pediatric patient during rapid sequence intubation, and we then review a systematic approach to the assessment of the pediatric patient in respiratory distress (ie, the pediatric assessment triangle) and conclude with a simple approach to pediatric rapid sequence intubation, starting with the preparatory phase and ending with postintubation management. We additionally highlight several alternative airway devices and discuss special situations, including rapid sequence intubation in the obese pediatric patient and in the difficult airway patient.

Case Presentation

You are working a day shift that you traded with your colleague when your local EMS calls in about a 4-year-old boy who apparently went to sleep last night “fine” but is now febrile, significantly altered, and exhibiting a petechial rash. The paramedics report a respiratory rate of 40 breaths per minute, a heart rate of 180 beats per minutes, a blood pressure of 50/palp, and an oxygen saturation of 84% despite the use of high-flow oxygen via facemask. The child is weak, has increased work of breathing, and has a grayish skin color. As the child arrives in your resuscitation room, several questions come to mind: How am I going to preoxygenate this child prior to intubation? What if he begins to vomit and occlude his airway? What if I can’t intubate or ventilate this child? What steps can I take to reduce the risk of him coding during the intubation? Why did I agree to work this shift?


Managing the pediatric patient who requires an advanced airway is a fundamental skill for physicians who work in the emergency department (ED). Although there are many pathways that lead to respiratory failure, there are only a handful of final common pathways that result in placing an endotracheal tube in the trachea of a sick child. Fortunately, complete respiratory failure in the pediatric patient is an uncommon event. Emergency clinicians should be prepared for the unique challenges posed by the anatomy and physiology of the pediatric airway, be familiar with the rapid assessment of the pediatric patient who requires intubation, be equipped with the standard and alternative sizes of pediatric airway devices, and have an organized approach to prepare for and execute successful pediatric rapid sequence intubation (RSI). This issue of Pediatric Emergency Medicine Practice presents an updated and systematic analysis of key principles regarding the pediatric airway, including newly recognized tips regarding preoxygenation and prevention of desaturation during airway management, the latest on the use of pretreatment, induction, and paralytic agents in pediatric RSI, and highlights the potential pitfalls of tracheal intubation with direct and video laryngoscopy.

Critical Appraisal Of The Literature

Unfortunately, there are few well-done prospective randomized controlled trials comparing intubation devices and techniques or pretreatment, induction, and paralytic medications in emergency pediatric intubation. The majority of data regarding these issues come from retrospective archives and chart reviews that report what was done and show an association between a particular device, technique, or medication and the overall outcome of the patient.

The nature of retrospective data limits the amount of information that can be abstracted from the medical record and ultimately cannot establish a cause-and-effect relationship between what is studied and the reported outcome. Prospective randomized trials that have been completed have had small sample sizes and may represent homogenous populations, thus limiting their external validity. Furthermore, the majority of data arise from the anesthesia literature, which pertains to elective pediatric intubations and not to the emergency or failing pediatric airway. Finally, there are areas within the airway literature where the best available evidence regarding pediatric techniques is extrapolated from the adult literature. These limitations should be kept in mind when reading this review.

Risk Management Pearls For Pediatric Airway Management

  1. Be absolutely sure that your endotracheal tube is in the central trachea and not in the esophagus.

    Use a combination of clinical signs and CO2 detectors or capnography, pulse oximetry, and chest radiography to verify proper placement.

  2. Be familiar with pediatric anatomy and physiology and anticipate that the critically ill child that requires intubation will likely desaturate quickly. Hypoxia must be avoided.
  3. Do everything you can to ensure proper preoxygenation prior to intubation. This includes airway positioning, use of oro/nasotracheal airway devices, positive pressure ventilation, and may even include placing an LMA prior to RSI.
  4. If you believe your patient is at high risk for vomiting and aspiration during RSI, consider decompressing the stomach with a nasogastric tube prior to intubation, positioning the patient in a sitting position during intubation, and pretreating with an antiemetic or prokinetic agent.
  5. Consider placing the pediatric patient in a cervical collar prior to interfacility transport. Some experts believe that the restricted head movement while in a cervical collar will prevent inadvertent tube dislodgement.
  6. Anticipate complications (desaturation, hypotension, bradycardia, vomiting, and acidosis) and take steps to avoid these complications prior to the administration of induction and paralytic agents.
  7. Have a difficult airway plan for patients with abnormal craniofacial anatomy and consider expert consultation, if time permits, for intubation of these patients.
  8. Do not paralyze a patient who has difficult airway anatomy and who you anticipate would be difficult to ventilate. Instead, consider an awake intubation in these patients.
  9. Disclose any difficulties with intubation and complications to the family. Let them know how difficult the situation was, what happened, and what steps you took to address the situation.
  10. Document any difficulties with intubation and complications in the medical record. Describe the situation, what happened, and the steps you took to address the situation.

Tables and Figures

Table 1. Anatomical Differences In The Airway Of The Young Child



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available.

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Amandeep Singh; Oron Frenkel

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