1. Failed Intubation in Children Dr Philip Ragg Royal Children’s Hospital Melbourne

2. Difficult Airway Management  Explosion of interest in airways  NAP-4 Guidelines 2011  “Difficult Airway Society” Algorithms  Video-laryngoscopes on the scene  Very little guidance for Paediatrics!!

3. APLS 2011 5 th Edition Recommendations  If intubation is impossible or unsuccessful consider: needle cricothyroidotomy ONLY if 12 yrs  Un-referenced

4. Structured Approach to Airway Management  Basic Manoeuvres  Adjuncts  Intubation  Surgical Airway  Clear, appropriate, logical sequence

5. Paediatric Scenarios for The Failed Intubation  Anticipated Failure due to Difficult Airway  Un-anticipated Failure (rare with experience) !  Complicating Factors:  Time available (stable patient, oxygenating, fasted)  No Time available (deteriorating, hypoxic, un-fasted) Walker RWM, Ellwood J. Paed Anesth. Review Article 2009:19;77-87

6. Golden Rules for Any Intubation  First - Assess the airway  Know your skill level  Always have a plan B  Any problem at any time - Call for help early  Prepare your equipment, environment, drugs  Optimize the patients position  OXYGENATION as Number 1 priority

7. Anticipated Failure to Intubate  Reasons may be: Congenital or Acquired Acute or Chronic Supra or Subglottic  Examples include: Syndromes (Pierre Robin, Treacher Collins, Goldenhar) Burns or Scarring or Trauma to face Haemangiomas Epiglotittis or Croup etc.

8. Assess the Airway  Dysmorphic features: small mandible, micrognathia, assymetry, large tongue, prominent teeth, syndromes  Limited mouth opening, neck movement, burns scars  Stridor or surface haemangiomas indicating possible tracheal pathology

9. Anticipated Failure  Planning: Staff (anaesthesia, surgical, experienced help) Equipment (laryngoscopes, adjuncts, fibreoptics) Drugs (for sedation, paralysis, anaesthesia)  Oxygenation technique: Bag and Mask Two operator technique Supra-glottic airways (guedel, nasal, copa, iGel) LMA  Follow an Algorithm

11. Un-anticipated Failed Intubation in a Child  EXTREMELY RARE in experienced hands  Morbidity and Mortality are due to failed oxygenation  Management of failed intubation must include: 1. Oxygenation Plan 2. Intubation Plan 3. Rescue Plan Weiss M and Engelhardt T. Proposal for Difficult Airway. Ped Anesth 2010:20;454-464

12. Oxygenation  Face mask bag ventilation/oxygenation is an ESSENTIAL skill required before intubation  If difficulties occur with oxygenation with a bag and mask consider :  Anatomical causes (e.g. tonsils/adenoids) and use jaw thrust, mouth opening, two operator, guedel airway  Functional causes (e.g. laryngospasm, bronchospasm) and consider sedatives, relaxants, anaesthesia

13. Pediatric Anesthesia November 2012 EDITORIAL Cannot ventilate – paralyze! Markus Weiss and Thomas Engelhardt Pediatric Anesthesia 2012 : 22 : 1147-49

14. Oxygenation  Face mask bag ventilation/oxygenation is an ESSENTIAL skill required before intubation  If difficulties occur with oxygenation with a bag and mask consider :  Anatomical causes (e.g. tonsils/adenoids) and use jaw thrust, mouth opening, two operator, guedel airway  Functional causes (e.g. laryngospasm, bronchospasm) and consider sedatives, relaxants, anaesthesia

15. Failed Oxygenation Plan A  Call for help if these manoeuvres fail  Perform Laryngoscopy and remove foreign body or suction secretions  Intubate with a suitable sized ETT

16. Failed Oxygenation Plan B  Insert an LMA if unable to visualise the vocal cords OR unable to insert the ETT.  If this is successful consider (degree of urgency): Waking the child if sedated OR Fibreoptic Intubation through the LMA OR Leaving the LMA until further help arrives

17. Tracheal Intubation  Teaching and Training are essential for success  Optimize conditions Range of Blades and ETT’s Age appropriate position of head and neck Consider sedation and anaesthesia External compression to bring larynx into view  Confirm placement (clinically, capnography)

18. Failed Intubation Plan A  Call for help early  Most experienced operator to consider need for:  Change of position  Different equipment (blades, adjuncts, introducer, Bougies)  Different approach (retromolar, paraglossal)  Consider new devices (if experienced and practiced!)  Video-laryngoscope (Glidescope, Airtrak, C-Mac, Pentax)  Fibreoptic devices (Ambu, Bronchoscopes)  Limit attempts to 3 to minimize trauma  Oxygenation between attempts

19. Failed Intubation Plan B  LMA device for oxygenation  Mount an ETT on fibreoptic bronchoscope to pass through LMA or Intubating LMA (iLMA)  Bougie or Oxygen Exchange Catheter can also be passed through LMA for ETT exchange.  If unsuccessful after 2 attempts – STOP  Use LMA for oxygenation

20. Rescue  Can’t Intubate and Can’t Oxygenate (CICO)  Worst situation imaginable  The child is going to DIE if nothing is done  Need to overcome the psychological barriers to proceeding from this point i.e. anything is worth trying

21. CICO rescue procedure  No good evidence in paediatric literature for preferred technique at this point:  3 choices :  1. Rigid Bronchoscope by experienced operator  2. Needle Cricothyroidotomy (Cook, VBM, Ravussin 13g, 14g, 16g)  High complication rate  60 % success in experienced hands !  3. Surgical Cricothyroidotomy / Tracheostomy  Traditionally discouraged < 12 yrs  Higher success rate in adult literature  Recently proposed as preference if < 6 yrs * * Engelhardt T, Weiss M. Curr Opinion Anesth 2012;25:326-332

22. Oxygenation techniques with cricothyroidotomy  Enk oxygen flow modulator (4 holes)  Oxygen tubing with hole  3.0 ETT connector and circuit (low flow)  Jet ventilation (set up time?)  Allow time (>4 seconds) for lung deflation to prevent baro-trauma

23. Needle or Surgical Airway  Require practice on simulators, manikins, cadavers or animals  Size appropriate equipment MUST be used  Cricothyroid puncture in infant or neonate is EXTREMELY DIFFICULT ( membrane is 2x3 mm ) and Trans-tracheal puncture with neck extension may be safer Cote CJ and Hartnick CJ. Ped Anesth 2009:19;66-76 Holm Knudsen et al. Ped Anesth 2012:22;1159-65

25. PREVENTION (skill, assessment, preparation) Oxygenation Face Mask Plan A: Larngoscopy Plan B: LMA Tracheal Intubation BURP, Position, Blades Plan A: Get help + Oxygenate Plan B: LMA Intubation + Oxygenate Rescue Rigid Bronch OR Needle Cricothyroidotomy OR Surgical Airway Failed OxygenationFailed intubation +

27. Summary  Practice techniques and failure plans  Optimize position, equipment, assistance  Call for help EARLY  Oxygenate at all times