A 3kg 23 day old baby presents to A&E; in a DGH with a history and examination findings suggestive of bronchiolitis. She is having hypoxic episodes with frequent apnoeas and bradycardic episodes. Following review by the Consultants in Paediatrics, Anaesthesia and Intensive Care, a decision is made that she requires intubation and respiratory support. She is transferred to theatres where she is anaesthetised. The three Consultants present are unable to intubate her but are, with difficulty, able to oxygenate her with a Mapleson F system and facemask with an oropharyngeal airway. What should be the next steps in her management plan?
The contents of a paediatric difficult airway trolley were the subject of an APA ‘Hot Topics’ review (http://www.apagbi.org.uk/professionals/education-and-training/apa-hot-topics).
Bronchiolitis and difficult intubation are subjects in the AAGBI’s ‘Tutorial of the Week’ (http://www.aagbi.org/education/educational-resources/tutorial-week/my-events/tutorial/Paediatric%20Anaesthesia).
A similar question posed at the previous NEPAN meeting raised the point that whilst a non-specialist hospital needs to stock a full range of emergency paediatric airway equipment (similar to that in the ‘hot topic’ review), it cannot be expected to have paediatric bronchoscopes available.
The DAS / APAGBI unanticipated difficult intubation guideline is more applicable to the context of surgery, but can be found at http://www.apagbi.org.uk/sites/default/files/images/APA2-UnantDiffTracInt-FINAL.pdf.
In the situation above, there isn’t realistically a ‘wake-up’ option, so the options would be the unpalatable decision to transfer without intubation, or to find a way of performing intubation.
Once direct laryngoscopy had been attempted with a range of blades, the next option would be indirect laryngoscopy with whichever of the indirect laryngoscopes that the physician was most familiar with.
Airtraqs and Glidescopes in particular are available in paediatric sizes, though the smaller blades of some other scopes may offer a view.
Should these methods fail, in the absence of a 2.2mm paediatric bronchoscope it is not possible to use a standard fibreoptic bronchoscope for endotracheal tubes of less than 4.5mm diameter. However, it is possible to visualise the cords and pass a guidewire into the trachea through the suction port of a standard fibreoptic scope.
The scope can then be withdrawn, leaving the wire in situ, which would then be used to guide an endotracheal tube into position.
This technique can also be used with an LMA as a conduit, with the added advantage that ventilation can be continued during intubation.
