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Pediatric Airway Management in the Emergency Department

Pediatric endotracheal intubation is an uncommon procedure in the Emergency Department (ED); even in high volume tertiary pediatric centres the incidence has been reported at 8-10/10,000 patients. While infrequent, pediatric airway management is an essential and life-saving skill that all ER physicians must be prepared for.  Much of the knowledge and skill set from the adult world is applicable here, however there are several important differences that are unique to the pediatric population.

This blog post aims to:
  • Provide a basic review of pediatric airway physiology + anatomy
  • Discuss predictors of the pediatric difficult airway
  • Review the literature on pediatric ER intubation practices and associated complications
  • Review Delayed Sequence Intubation (DSI) and the pediatric surgical airway

Pediatric Airway Anatomy and Physiology Review

1. Anatomic differences in the pediatric airway are more pronounced in younger children, especially under 1 year, and have important implications for airway management

These include:

  • Large occiput + head à Add a shoulder roll to align the airway axes
  • Large Tongue à obstruction more common, maneuvers to open the airway may be necessary (eg jaw thrust)
  • Superior larynx and anterior vocal cords + floppy epiglottis à visualization can be more challenging, consider a straight blade in younger children to lift the large epiglottis
  • Large stomach with relatively small lungs à consider early NG tube

Walls, R. 2012. Manual of Emergency Airway Management, 4th Edition

2. Physiologically, kids have a considerably shorter time to desaturation than adults and their relatively larger extracellular fluid compartment means a quicker onset and shorter duration of RSI drugs16

  • There are many different equations out there to figure out sizing of tubes, blades, masks, etc., but the bottom line is that it’s too much to memorize for something you won’t need to use often, so to reduce error in critical situations use memory aids such as the Broselow tape or your favourite medical app
    PediStat -- a commonly used pediatric reference application

    3. Difficult intubation seems to be rare in children, but increases in incidence in the <1 yo population. 

    This retrospective analysis of 11,219 pediatric anesthesia procedures found that the overall incidence of difficult laryngoscopy to be only 1.35%. The paper highlighted some predictors of a difficult pediatric airway, which included:
    • < 1 year old
    • Mallampati score (if attainable) III + IV
    • Low BMI
    • Children undergoing cardiac and oromaxillofacial surgery patients – likely due to higher proportion craniofacial dysmorphisms eg. Cleft palate, micrognathia

    ER Pediatric Intubation Practices and Complications

    1. Pediatric endotracheal intubation is an uncommon procedure, but resulting desaturation and hypotension are frequent complications

    This prospective observational study reviews pediatric intubations in a tertiary pediatric ED. Their primary and secondary outcomes were, respectively, the rate of adverse effects during intubation and the incidence of difficult laryngoscopy and first pass success rate without desaturation and hypotension.
    • The incidence of pediatric intubations was found to be 9/10,000
    • 79% of intubations were for medical conditions (seizure most commonly), 21% were for trauma
    • Median age was 3, with 25% of intubations being in the <1 population
    • First pass success rate was 78%
    • First pass rate without hypotension or hypoxia was only 49%
    • Difficult intubation was seen in 7% of cases, but all intubations were ultimately successful
    • Ketamine was the most commonly used mono-agent and was the induction agent of choice in patients with CVS compromise

    2. Desaturation and hypotension peri-intubation matter, as they are linked to poor neurologic outcomes and are predictors of airway mortality 12 

    A review of 1081 difficult airways found that 1% were associated with cardiac arrest, all preceded by hypoxemia.  Occurrence of complications in the difficult airway was associated with: 
    • More than two intubation attempts
    • Weight < 10kg
    • Short thyromental distance
    • 3 direct laryngoscopy attempts before switching to indirect technique
      3. Direct Laryngoscopy is a reasonable first line choice, but the Pediatric Difficult Intubation (PeDI) registry data suggests we should be thinking about switching to an indirect method much sooner if we run into trouble.  

      In fact, first attempt success rates in the pediatric difficult airway population were found to be substantially higher in Video than in Direct Laryngoscopy (55 % vs 3 %)4. This begs the question as to whether community and ERs that see primarily adults should be stocking pediatric video laryngoscopes?

      Keep in mind, though, that this is the difficult airway population, which we know is quite rare.  A systematic review of 14 prospective RCTs comparing video vs direct in the pediatric population concluded that although video improved glottis visualization, it was associated with prolonged time to intubation -- something to consider given the considerably reduced safe apnea time in children.

      Delayed Sequence Intubation and The Pediatric Surgical Airway

      Scott Weingart’s group has paved the way for future studies on Delayed Sequence Intubation (DSI)1; keep an eye out for this in the pediatric population as it’s easy to see how it might be useful in the agitated hypoxic child that needs to be intubated

      The concept is to use ketamine as an induction agent to facilitate pre-oxygenation while keeping the patient spontaneously breathing in situations where RSI would likely lead to  hypoxia. While the evidence is still in it’s infancy, case reports 2,3 are surfacing of DSI being successfully used to secure the airway in agitated hypoxic and critically ill patients.

      ASA 2013 Difficult Airway Algorithm

      Finally, if you find yourself in the exceedingly rare but completely terrifying can’t intubate, can’t ventilate scenario with a pediatric patient, remember that needle cricothyrotomy is indicated in younger children14
      • The literature in this area is sparse and there is no consensus on a definite age cut off for needle vs open cricothyrotomy, it will depend on how difficult landmarking is and the size of the cricothyroid membrane (CTM). 
      • Consider using a Seldinger technique to transition to open once needle is secured if needle ventilation continues to be inadequate and help has not yet arrived
      • Anatomical differences making the traditional surgical airway challenging in this population include a smaller CTM, more compliant larynx and the thyroid cartilage riding under the hyoid bone.

      Dr. Rebecca Brown, MD, CCFP is a 3rd year resident in the CCFP-EM program at the University of Ottawa.

      Edited and Formatted by Dr. Rob Suttie, PGY2 at the University of Ottawa

      1.     Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med. 2015;65:349-355.
      5.     Nishisaki A, Turner D a, Brown C a, Walls RM, Nadkarni VM. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med. 2013;41(3):874-885
      6.     Walls RM. Emergency Airway Management: A Multi-Center Report of 8937 Emergency Department Intubations. J Emerg Med. 2011;41(4).
      7.     Anesthesiologists A society of. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-270
      8.     Choi HJ, Je SM, Kim JH, Kim E. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: A 13-emergency-department registry study. Resuscitation. 2012;83(11):1363-1368
      9.     CotÉ CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: Which are appropriate for infants and children? Paediatr Anaesth. 2009;19(SUPPL. 1):66-76.
      10.   Fiadjoe JE, Stricker PA, Litman RS. Pediatric Airway Management. Greg Pediatr Anesth Fifth Ed. 2011;26:300-329
      11.   Gencorelli FJ, Fields RG, Litman RS. Complications during rapid sequence induction of general anesthesia in children: A benchmark study. Paediatr Anaesth. 2010;20(5):421-424.
      12.   Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013; 84(11):1500-1504.
      14.   Jagannathan N, Sohn L, Fiadjoe JE. Paediatric difficult airway management: what every anaesthetist should know! Br J Anaesth. 2016;(i)
      16.   Walls, R. Manual of Emergency Airway Management, 2012, 4th Edition 1.     


      1. A couple of comments/questions specifically for Pediatric Surgical Airway:

        1. Low-pressure oxygen source for cannula cricothyrotomy. Can you be more specific about flow and/or pressure?
        2. IVs have a high risk of kinking: there are re-enforced cannulas made for this rare situation situation
        3. Attaching the end of an ETT to an IV catheter has a high risk of kinking at the skin There are other commercially available options available

        There are much better systems aside from the 'home made' ones suggested for this once-in-a-career emergency. We should be using them. Will be posting the Vancouver Island Trauma Rounds about pediatric surgical airway options from last week on twitter when it becomes available.

        There is also a section specifically addressing Paediatrics in the Canadian Airway Focus Group Guidelines 2013.

        Happy to discuss further if you like, thanks for bringing up and discussing pediatric difficult airway. Some good recent publications and a nice review of them.
        All the best,

        1. Hi Dr. Duggan, thanks for the comments and questions. I'm going to try to get Dr. Rebecca brown to answer your first question.

          In regards to your comments regarding the re-enforced cannulas and commercially available kits, do you have any suggestions? Anything that you have experience with? I always find the balance between a "home-made" solution vs a commercial kit in those once in a lifetime situations a tough one. On one hand, most of the resources on this will tell you how to put together something that works, however you'll likely have to put it together at a very fast pace, nerve-wracking time. On the other, the commercially available kit will be easy to put together, however sometimes you have no idea where you put it since it's been a long time since someone last used it! =D
          Would love to hear more about it, perhaps something our ED could consider purchasing.

          Please send us the link to your rounds once they are available!



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