Normal and Difficult Airways in Children: “What’s New”‐ Current Evidence- John Fiadjoe and Akira Nishisaki

John Fiadjoe

Akira Nishisaki- Teaching

First published: 23 December 2019

https://doi.org/10.1111/pan.13798

Abstract

Background

Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the Operating Room (OR), intensive care unit, Emergency Department, and neonatal intensive care unit.

Methods

Expert review of the recent literature.

Results

Cognitive factors, teamwork and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated video laryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are however, substantial differences among video laryngoscopes particularly angulated vs. non‐angulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the Pediatric ICU, ED, and neonatal ICUs, adverse tracheal intubation associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the OR and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the OR. Similarly, a multicenter Neonatal ICU study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration.

Conclusions

Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with ICU, ED, and Neonatology clinicians to improve the safety of airway management in all clinical settings.

The Concept of "The Army of the Willing." Airway Observer Dr Jack Pacey

Personal Note

It gives me great pleasure to follow the efforts of my wonderful friends in the airway world.
The utility of the video Laryngoscope is now well established but nothing is magic and nothing is so good it cannot be replaced and improved on.

One of my great memories was going to midlevel residents in University teaching hospitals and telling them
Demonstrating the Glidescope ....If you learn how to use this device you will be the "Go To " person in your department for difficult airways and you can build your career on the basis of leading change in airway management.
I would then observe the faculty as they adopted quickly or slowly depending on their attitude towards change. I knew that attitude was the most important quality.

"The Army of the Willing"
This is a phrase which I adopted to determine how long I was prepared to spend educating a potential user. If someone was eager I would spend all day but if they had a poor attitude I would move on to find the willing learner in seconds .
Always spend your maximum teaching effort on the willing potential enthusiast.

Thankfully the Verathon Glidescope team is executing brilliantly on my original vision and also on new ideas that are truly spectacular..



PaceyCuff.com

JB Brodsky-Core Topics in Anesthesia and Perioperative care 2018 -VL

New Book : Comments about VL combined with Cricoid Pressure

Professor JB Brodsky is a Stanford based Anesthesiologist focused on advanced airway applications to Obesity Surgery and Thoracic Anesthesia with an interesting observation about use of Video laryngoscopy and Rapid Sequence intubation.

Professor Brodsky notes that the controversial item of cricoid pressure application may be a problem with video laryngoscopy application.

Highly Angled Video Laryngoscopy Blades (eg. GlideScope and Mcgrath)

• The physical lifting of the tip of the laryngoscope blade is often not appreciated by the casual user. Those familiar with classic DL blades increase lifting effort when ever they have a problem with the view. Usually backing off the tip of the blade by 1/2 -1 cm is the correct response . increased force of lifting of the tip can produce such angulation of the airway with a peak at the cricoid position that even though the view seems to be excellent there is no way to pass the ETT into the descending trachea. Brodsky points out that pressure on the cricoid actually increases this airway distortion and makes intubation even more difficult.

• Bottom line is that the skilled user must ask the question: what are my efforts doing to deform the airway?  The usual answer is that a very light lift of the tongue with minimal lift of the tip of the blade will allow you to see and easily pass the ETT into the trachea which normally lies just anterior to the esophagus and should remain there.

• The use of the directive stylet is essential to have a high degree of control of the endotracheal tube and this device should be used with a gentle touch under visual control to avoid unnecessary injury to the palate or tonsils.

Direct Viewing Video Laryngoscope Blades ( typical Storz Blade and Glidescope Direct)

• There is less problem with these blades because they do less distortion of the airway.

• The direct blade is just that and it will be unable to handle more challenging airway anatomy because it is fundamentally a direct laryngoscope albeit a more effective one.

• The direct blade is easier to use for new users of video laryngoscopy and is excellent for training and development of airway skills.

Conclusion:

Professor Brodsky's point may be a bit subtle but one must understand this to be a truly skilled video airway expert.


Pacey Cuff     < : click to see Dr. Pacey"s urologic blog. 

It is time for "High Flow Nasal Oxygen" to be included in the Difficult Airway Strategy

ADVANCED OXYGEN DELIVERY 2018

Urgent Need to add Hi Delivery Nasal Oxygen to Algorithms

The tool kit available for airway management has evolved rapidly in the last 20 years to include the following :

1. There are algorithms such as the ASA Difficult Airway Algorithm 2013, the DAS  (UK) Algorithm and the Canadian Focus Group Recommendations. 

2. Training including Airway Fellowships have been developed.

3. Equipment has been developed and proven to be effective in situations where Practitioners have been trained to a competent level with the devices prior to emergency events.

4. The Airway Tool Kit includes:

      a. oxygen delivery by preoxygenation, nasal oxygenation, Nasal CPAP (as Per James Tse), 

          and Hi Flow oxygen  such as Thrive.

      b. Oral and nasal airways

      c.  Supraglottic Airways

      d. Tracheal Intubation- Direct Laryngoscopy

      e.  Tracheal Intubation- Video Laryngoscopy

      f.  Tracheal Intubation - Flexible Scope application

      g. Direct Surgical Airway 

      h.  ECMO

N Shallik and A Karmakar  , Doha Qatar , online June 25, 2018

DOI:https://doi.org/10.1016/j.bja.2018.05.052

The above authors have suggested that there is urgency to place the advanced methods of Oxygen Delivery such as Hi Flow Nasal O2 into the Difficult Airway algorithms forthwith.

The world moves at a different pace at this time.

The ASA Algorithm 2013 should be updated immediately to avoid a gap in application of advanced oxygenation methods known to extend the period of acceptable blood oxygen levels by minutes . These nethods include high flow  (Thrive) and also Nasal CPAP oxygen .

The risk of inclusion of these excellent methods as an urgent need is close to zero because there are few side effects and the oxygen provides an extended working and thinking time for care givers.

Glidescope versus McGrath Video Laryngoscope used by Anesthetic Residents- Thailand

Journal of the Medical Association of Thailand

 J Med Assoc Thai 2018 , 101 (6): 803

Comparison of Glidescope and McGrath Video Laryngoscope for Intubation and Adverse Events by Anesthetic Residents

Methods:

A prospective randomized trial was performed with 40 patients betweenthe ages of 18-65 who were ASA Class I-III for elective surgery. Patients were randomly allocated to : Glidescope group or the McGrath group using computer generated numbers applied to a group of first year anesthesia residents with a minimum of 3-6 months experience with Direct Laryngoscopy.

The operator measured and recorded the intubation time , number of attempts, complications and vital signs.

Results:

Intubation time was significantly shorter for the Glidescope when compared to the McGrath laryngoscope ( 26.8 sec. vs 55.1 sec.

  The number of intubation attempts as well as the complications were not significantly different between the 2 groups.

Conclusion:

Intubation time was significantly less with the Glidescope group of patients than the McGrath group.

Comment:

As I am the Glidescope inventor my comments will reflect my greater knowledge of the Glidescope which preceded the other device. The differences between the various video laryngoscopes is ofter minimized but there are marked differences in behavior of the highly angled (60 degree) laryngoscopes and the lesser angled devices and the intelligent user will know these differences and will apply the knowledge when choosing the tool best suited to the anatomy of the patient.

The Glidescope and McGrath devices both belong to the highly angled laryngoscope group and therefore may behave similarly. What accounts for the finding of difference in intubation time in this study?

The Glidescope ergonomics may account for the superior performance seen in this study. The great attention to detail in design may even result in more confidence especially in this group of first time users. There is great science in other fields that develops superior user interface features. Medical devices may not have such attention to detail when engineering is being implemented. The superb ergonomics of the Glidescope is well known.

See also PaceyCuff.com

The Age of Automated Secretion Clearing

Automated Secretion Clearing

Normal is a Wonderful Thing.

    When we do our learning and get it all right such that we can chant to Next Gen. Medical staff the teachings from the mountain and have them all copy the notes to perfection. Now assign the required degree.......its a comfortable world that allows us to apply the "Normative" solutions until we are jarred into reality by the new teachings that make us change.

    Time has increasingly taught us to expect changes and disrupt our comfortable conventions.

Airway Conventions.

   Intubation and ventilation for those who are not able to sustain life giving O2 CO2 exchange we know is at this time essential lifesaving treatment. The human airway produces 200-500 cc of fluid and protein exudates or transudates every 24 hours and we accept that we must suction these fluids from their position trapped below our endotracheal cuff. We also accept that regular airway suctioning is required when we  sense that this fluid is beginning to block airway.  There is a potential for contamination of the airway with each passage of the suction so we enclose the suction in a sheath to prevent contamination. All of this is laudable but can we do better?

• What if ?  we were able to ventilate efficiently and prevent the Endotracheal tube cuff from trapping all secretions close to the lungs.
• What if ?  every stroke of the ventilator acted like a bilge pump that extracted secretions with the CO2 and Nitrogen.
• What if? The oxygen tension in the trachea was always higher than with standard tubes.
• What if ? The dead space was dramatically reduced and air trapping was unlikely.

The Pacey Secretion Clearing Endotracheal tube.

Please stand by because all of this is and more possible with the new technology Secretion Clearing Endotracheal tube. More detail is inevitable.

PaceyCuff.com Urethral (R) control device controls urinary incontinence -look for Pacey Cuff on Amazon

Near Perfection in Airway Management is now Possible #6

Airway Management Academy Founded 2013 - Netherlands

     I speak often about the UK Concept of " designating an Airway Lead" for your hospital. The individual seeking that role must have the drive to go out and get the skills and then bring these back to the institution and convince fellow Doctors that he or she is the person to lead the charge in developing local airway leadership.

    The restless ambition and enthusiasm for teaching Airway Management Excellence is nowhere more clearly exhibited that in the case of Dr. Hans Huitink from the Mobile Anesthesiology Service Holland Foundation . Hans and his co-workers are passionate super stars who have dedicated themselves to excellence in airway management and their association has created a non-profit teaching organization  Airway Management Academy with teaching locations in Amsterdam, the Netherlands, Bern Switzerland , and Doha Qatar. Courses are offered in English, Dutch, and German languages. Experts from many countries contribute to the programs and the offsite courses.

    This is but 1 example of many high level learning opportunities that may form the core learning platform for those aspiring to be " UK style Hospital Airway Leads".  This type of learning assures that one will be mixing and meeting with the best minds available.

    Hans has developed a very dynamic team and has created a CE approved  Airway Triage Ap available for Apple devices via the I store for 3.49 Euros . This Ap provides practitioners with a valuable tool that will keep patients safe in a systematic way that can fit well with a teaching program for your "Airway Leads" to , in one step,  bring airway decision support where it is needed  at the bedside.  The development of electronic medical decision support is now in its infancy but will sweep into clinical care like a tidal wave very soon. 

      No more mindless decisions to cause one to wade in where angels fear to tread. The Ap will not escape the attention of shrewd Legal experts who can and will use it for a devastating law suit results.

   The following Major organizations are now available to build community for the Local Hospital Airway Lead:

• The Society For Airway Management SAM
• The UK Difficult Airway Society DAS
• The European Difficult Airway Society
• The Chinese Difficult Airway Society
• The World Airway Management Meeting WAMM (Amsterdam 2019)

   The new tools and the new training opportunities allow excellence to be learned and taught worldwide. I attended the initial meeting of the Chinese Difficult Airway Society  2010 with , I was told starting Membership of 500.  Very keen and impressive key Chinese Anesthesiologists were eagerly preparing to learn and add to the worlds collective airway expertise. 


Pacey Cuff Urethral (R) control device controls urinary incontinence -look for Pacey Cuff on Amazon or PaceyCuff.com