Current Reviews for Nurse Anesthetists Pediatric Difficult Airway Management Approaches for Success
Context
Akershus University Hospital (AUH) has ~5.000 deliveries per year and the level ii–3 NICU provides intendance for newborn infants from 26 weeks gestation. A pediatric resident and a general pediatrician are responsible for initial resuscitation and stabilization of newborns in the evening and dark with an on-call neonatologist at home with a 30-min response time. The neonatal resuscitation team is chosen for when a baby is in unexpectedly poor condition at birth, and consists of a pediatric resident, a consultant neonatologist (or pediatrician) and a nurse from the NICU. At cesarean deliveries, more rarely in vaginal deliveries, one or more anesthesiologists is/are present for the care of the mother and will offer assist if the neonate is depressed and requires resuscitation. The regional and national referral hospital that cares for most of the extremely pre-term infants in the region, is located only 21 km away.
Introduction
Roughly five% of newborns demand respiratory support such as positive pressure level ventilation (PPV) to successfully overcome the phase from fetal to extrauterine life. Of these iii–10% may non respond to mask ventilation leading to an attempt to intubate (1–3). Airway direction is a core skill in neonatology and anesthesiology. Endotracheal intubation (ETI) of neonates in delivery rooms (DR) and neonatal intensive intendance units (NICU) is a process associated with a risk of complications and airway injury. The DR and NICU serve different purposes in the stabilization of organ systems, evolution, and growth. DR medical intendance emphasizes support of the immediate period after nascency where resuscitation including avant-garde airway management is often anticipated. NICU medical care more oftentimes focuses on maintaining stabilized organ systems and providing nutrition for evolution and growth (4, five). The incidences of astute resuscitative NICU intubations varies between units but are ofttimes less expected (4). Analysis of ETIs performed in the DR and NICU shows that significant differences in patient, provider, do characteristics, and in the employ of airway adjuncts be (vi).
Anatomical and Functional Differences Between Neonates and Older Children and Adults
Knowledge of neonatal airway anatomy is important during ETI to avoid pharyngeal obstruction, and to accurately assess the larynx. In airway management, the key anatomical structures are located from the lips and nostrils to the carina. Distinct features of the neonatal airway, besides seen at laryngoscopy, compared to older children/adults include (7):
• Neonates are preferential nasal breathers and may have difficulty breathing through the mouth to sustain respiration when the nostrils are obstructed.
• The natural language is relatively large.
• The epiglottis is larger, longer, less flexible, and narrower.
• The larynx lies higher and more than anterior to the cervical vertebrae reaching the 'adult' position by around 6 years of age.
• The larynx is funnel-shaped and the subglottis (the outlet of the cricoid ring) is the narrowest part rather than the glottis in older patients.
• The neonatal airway is more than prone to inspiratory collapse and obstacle due to a lack of posterior tracheal cartilage.
• Facial and head abnormalities, abnormal neck mobility, modest mouth opening (modest mandibles), and cervix and airway masses may all interfere with visualization of the larynx, positioning, insertion of laryngoscope, tube placement, and ventilation both by mask and after intubation.
Alignment of the trachea, the pharyngeal and laryngeal inlet must be achieved to avoid airway obstruction in the neonate during mask ventilation and to optimize the view of the laryngeal inlet during intubation. This can often exist achieved by placing a towel coil under the shoulders to obtain a neutral position of the head and cervix. "Grade of intubation views" is described in the Cormack-Lehane four-grade nomenclature (viii) and the modified Cook'south classification (Figure 1) where "easy" views require no adjuncts; "restricted" views crave a bougie; and "hard" views require avant-garde techniques to intubate" (9). Neither of these classifications has been modified to utilise to neonates.
Effigy 1. The modified Cook'south applied classification of laryngeal view. "The view is easy (East) when the laryngeal inlet is visible. These views are suitable for intubation under direct vision. The view is restricted (R) when the posterior glottic structures (posterior commissure or arytenoid cartilages) are visible or the epiglottis is visible and can be lifted. These views are likely to benefit from indirect methods (e.one thousand., gum rubberband bougie). A difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. These views are probable to need advanced methods for intubation." The figure and text are reproduced from "A new applied nomenclature of laryngeal view; Anesthesia, 2000, 55, 260–287" with permission from Prof. T. Thousand. Cook, MD, 21.01.2021, and RightsLink/John Wiley and Sons. The photographic part (with the blue background) minus photo "Course 3b" (Class 3b: Reprinted with permission from openairway.org.) forth with other modest changes by author G. Berisha, Physician, has been reproduced with permission from Carin A. Hagberg, Medico, FASA, 08.x.2021.
The Unexpected Difficult Airway in the Neonate
Whenever there are struggles with face mask ventilation, laryngoscopy, endotracheal intubation, and/or use of a supraglottic device "a difficult airway" situation arises (10, 11). In adult and pediatric intensive care, a 'difficult intubation' involves three or more attempts at laryngoscopy by an experienced wellness care worker (HCW) (12). The incidence of hard intubations in the adult intensive care unit of measurement (ICU) is 8–11% (13) and in the pediatric ICU ix% (14). The extent of intubation difficulties in the DR and NICU is unknown, merely a review by Sawyer et al. (12) indicated a 14% NICU incidence. Difficult intubations were more common in small pre-mature neonates and highly linked to adverse events and severe oxygen desaturations (12).
Neonatal intendance in the first minutes of life focuses on lung aeration (15–17). Any difficulty encountered in opening and maintaining the airway may have dramatic cardiopulmonary consequences. A true difficult airway, e.chiliad., airway malformation, may be rare in neonates (5). Still, repeated instrumentation of the airway may result in bleeding, airway edema, and tissue trauma and a "can't ventilate, can't intubate" situation (5). Feel from anesthesiology is that algorithms, accelerate planning and routine practicing of a difficult airway approach optimize team responses to the technical and non-technical requirements of such situations (5). In neonatology, such advance plans may be lacking. We observed current approaches to advanced airway management in DR resuscitations in a Norwegian university hospital and reviewed the literature to provide recommendations most neonatal difficult airway direction.
Observations of DR Direction of an Unexpected Hard Airway
The Regional Commission for Medical and Wellness Inquiry Ethics and the hospital institutional review board approved the project. Motion-activated video cameras with sound (Hikvision 2 megapixel IP camera, Hangzhou, Mainland china) were installed on all DR resuscitation cribs, focusing on the baby and the hands of the HCWs. All infants placed on a resuscitation crib August 2014-November 2016 were filmed and the videos were assessed for eligibility. The videos that contained positive pressure ventilation (PPV) were downloaded to a reckoner and transcribed. At the time of the video recordings, our NICU had no hard airway algorithm or guideline. A inquiry assistant with no applied neonatal resuscitation experience transcribed the videos using Interact software version 9 (Mangold Int GmbH, Arnstorf, Germany). A pediatrician (AMB) transcribed a selection of the recordings independently before the recordings were erased. There was minimal interrater bias. ALS, a consultant neonatologist, and GB, a consultant anesthesiologist, analyzed the transcripts quantitatively and qualitatively, and GB processed the information furthermore for statistical analyses.
This newspaper reports secondary analyses of some video transcripts that we previously reported in (1, eighteen, 19). The transcripts include information well-nigh profession/role of involved HCW, dialogue, provision of PPV and chest compressions (CC), and ETI attempts. The transcripts also include verbal assessment of PPV effectiveness, as well as visible breast rise and functioning of ventilation corrective deportment.
Xx-3 out of 314 (vii.3%) eligible transcripts included ETI attempts. Table 1 presents characteristics of the infants that underwent intubation attempts and quality assessments of the attempts using the intubation subscale of the Neonatal Resuscitation Performance Evaluation (NRPE) score (20). In nearly two thirds of the infants, three or more intubation attempts were required, and four infants spontaneously recovered afterwards several failed attempts by multiple persons. Capnography was used in seven (30%) of the patients (Table 1). Our NICU did non have laryngeal mask airway (LMA) or videolaryngoscopy (VL) bachelor during the years of information collection. Stylets were available, but no pediatric or neonatal sized bougies. Employ of a VL gives the benefit of direct observation of ETI. The do good of directly observation besides helps with troubleshooting due east.g., if an infant does not amend despite successful intubation observed on VL, one should consider the possibility of a also deep ETT, a demand to increase the inflation pressure, air leak, and thick mucilaginous secretions needing deeper suction, rather than ending up in a roughshod cycle of removing the ETT and reintubate.
Table i. Characteristics of the infants (n = 23) that were intubated or underwent intubation attempts and the intubation attempts (north = 68).
Nasal and oral intubation was performed as oft. The mean (range) try duration was 44 (xiv–100) seconds, and the number of intubation attempts per HCW was three (ii–6). Ten infants were successfully intubated by a consultant neonatologist and 5 by the anesthesia team. The remaining eight infants were intubated past a pediatric resident or consultant pediatrician. No pre-medication was given in any of the DR intubations (Tabular array 1).
Review of the Literature
We conducted a focused, but non-systematic search to find evidence of approaches to a difficult neonatal airway. The search was performed in MEDLINE, EMBASE, Pubmed Central and Web of science. The final search was performed 31.12.2020. We used a combination of fundamental words and MeSH or EMTREE headings to describe "unexpected difficult airway in neonatal resuscitation," "adverse events in neonatal tracheal intubation during resuscitation," and "failed intubations in neonatal resuscitation." Reviews, adept opinions, registry- and instance studies were included, in addition to original studies.
Mask Ventilation Difficulties
Face up mask leak and airway obstruction are common during the first 2 min of PPV (21). Many reports suggest an increased risks of air leak with the widespread apply of T-slice resuscitators in term resuscitation, and mask CPAP causing both brain and lung injuries i.e., intraventricular hematoma (22). Ineffective troubleshooting of suboptimal mask ventilation may occur partially due to a lack of knowledge of difficult airway management devices and skills for practical awarding (23).
Nasal vs. Oral Intubation
In 2008, Jonathan Wyllie recommended that in an emergency, oral intubation should be the first choice as it decreases intubation time, is more probable to be successful on first try and is less traumatic (24). However, the option between primary nasal and oral intubation remains mainly driven past institutional preference and HCW experience (25). Nasally placed tubes take been perceived to be more secure and comfy for neonatal patients (25). However, a Cochrane review found no clear advantage of either nasal or oral intubation of newborn infants with respect to tissue trauma, infection, tube malposition/blockage/dislodgement, adventitious extubation or re-intubation (26). Forty-one percent of neonatal patients presenting for cardiac surgery were nasally intubated in a retrospective report analyzing intubation road and perioperative outcomes (27). In this population, significantly less accidental and transesophageal echocardiogram related extubation occurred in infants that were nasally vs. orally intubated. There was no divergence in airway complications between routes of intubation.
Tracheal Tube Introducers
Tracheal tube introducers (TTI) also called gum elastic bougies are 'difficult airway' devices that are besides used as airway exchange introducers and to facilitate both intubation and extubation (28). Both TTIs and stylets have proven to be useful in the management of hard airways in adults where early on application is recommended (29). There are both direct and distal angled types TTIs for use downward to endotracheal tube size 2.v–3.0–3.5 (30). Vygon'southward Bougie Boussignac has been used successfully in the intubation of infants with Pierre Robin Syndrome (31, 32) and TTIs and stylets combine well with videolaryngoscopy (33). Reports of complications with the employ of bougies in neonates include pneumothoraxes and bronchial trauma (34) and controversy be nearly under which circumstances, if whatever, a neonatal bougie should be used (34).
Other Airway Adjuncts
Videolaryngoscope (VL) (35) and supraglottic airway devices (SAD) such as LMA (36) are increasingly used in neonates (37, 38) as companies develop equipment for use at lower gestations (39, 40). LMA is recommended in the 2020 European Resuscitation Quango (ERC) guidelines every bit an offshoot in infants of 34 weeks gestation or more (17).
View of the glottis is improved by VL, which may also lower the risk of unfavorable events associated with neonatal ETI (5, 6). VLs are portable and can be used in both the DR and the NICU. VLs may exist specially useful in the management of an anticipated difficult airway situation e.g., airway malformations and anomalies (41). Trials accept shown improved neonatal ETI success rates when trainees use VL instead of conventional laryngoscopy (12, 13) and VL during neonatal ETI has been independently associated with a reduction in unfavorable events (42). Overall, these findings propose that VL may optimize the condom and success of neonatal ETI.
Fiberoptic Intubation
The "gilded standard" for difficult pediatric airway management is fiberoptic-guided ETI, i.e., fiberoptic bronchoscopy (FOB). However, there is a paucity of data on neonatal utilise of FOB during intubation and controlled extubation (43, 44). The technique of using a Deplorable as a conduit for Fox-guided intubation may reduce blurring of the vision caused by claret and secretions (45) and is recommended as an option to resolve the unanticipated difficult airway situation in children (29). Contempo example reports and studies conclude that the technique is an effective and condom option in the anticipated and unanticipated difficult airway in neonates and infants (43, 44).
Pre-medication
If time allows, systemic pre-medication should be used to optimize the chance of achieving ETI at the first attempt. However, sick neonates at delivery, in the NICU, or in the operating room may lack physiological reserve, pre-disposing to rapid compromise when innate respiratory effort is lost (iv, 46, 47). Especially the employ of muscle relaxants may crusade a state of affairs of "point of no return." In the case of an expected difficult airway, e.thou., short cervix or hypotonia, an culling arroyo to relaxation may be topical lidocaine at the laryngeal inlet (48–50). Topicalization of the airway involves applying a local anesthetic over an area of mucosa to accomplish regional neural blockade. Topical lidocaine reduces airway reflexes, swallowing reflex and cough by blocking sensory receptors. Airway instrumentation and intubation tin can exist performed one.5–2 min after lidocaine topicalization, e.grand., with customized spray devices (fifty). The recommended neonatal dose is iii–4 mg/kg (l). Lidocaine topicalization can shorten the neonatal intubation time whilst preserving blood force per unit area, heart rate and oxygen saturation (49).
Nasal drugs for procedural sedation and analgesia in neonates are increasing (51–55) and may be used equally pre-medication earlier intubation of newborns. Milési et al. compared intranasal midazolam and ketamine for neonatal intubation in pre-term neonates and constitute that the initial respiratory and hemodynamic tolerance of the two drugs were comparable despite 2–4 mg/kg nasal ketamine being less efficient than nasal midazolam in rapidly achieving adequate sedation for intubation (54). Also of annotation, despite relatively petty piece of work reported on its use, when having ventilation and intubation difficulties, intralingual or submental suxamethonium offers a possibility to resolve the trouble (56).
Emergency Surgical Airway/Front of Neck Access (FONA)
Establishing a front of neck airway in infants <two kg or <36 weeks post-menstrual age can be difficult due to the neonatal airway anatomy, especially the short cervix and relatively thick anterior neck tissues (57, 58). Nether full general anesthesia, an elective surgical airway (tracheostomy) can exist established in neonates weighing <2 kg. Suboptimal conditions and the added stress and time pressure level in an unexpected difficult airway situation, are likely to reduce the chances of success even in trained hands. In adults and older children, the cervix anatomy allows for needle cricothyroidotomy as a potential rescue technique in a "can't intubate/can't ventilate" scenario. An attempt to perform needle cricothyroidotomy equally the start FONA option is recommended in children in the absence of an ENT specialist (59, 60). However, unfortunately, this procedure has been shown to have a failure rate of 65% in adults (61). In neonates, cricothyroidotomy by scalpel or needle is not possible because of the small sized cricothyroid membrane and neonatal subglottis (62, 63). Establishing effective respiration (oxygenation and ventilation) apace while fugitive damage to the anatomical structures is the goal of a neonatal surgical airway. Therefore, FONA is non recommended for the direction of a difficult neonatal airway in centers without pediatric ear, nose, and pharynx (ENT) services (v). A "can't intubate/can't ventilate" scenario is rare and frightening. Training for such events is difficult equally simulator and airway models only partially resemble the neonatal airway anatomy. Regular training likely decreases HCWs reluctance to establish a surgical airway. Both technical and non-technical skills needed for performing a surgical airway and managing a neonatal "tin can't intubate/tin't ventilate" scenario should be adept and trained.
Policies and Procedures
Skilled airway management is required even for anatomically normal neonatal airways (64). In expected and unexpected difficult intubation in children, patients <10 kg are more prone to complications than larger patients (65). This is considering of rapid desaturation due to a lower functional residual capacity and college oxygen consumption, likewise as lower success rates of avant-garde airway rescue techniques (25, 66). Therefore, any airway management procedure should anticipate the possible failure of and plan one footstep ahead. Policies for managing neonatal intubation depend on the clinical setting in which the intendance is being given (vi). In UK NICUs a difficult airway approach or plan is not universally present (67). This is expressed as variations in the allowed or expected number/quality/duration of intubation attempts by a single HCW (68, 69). Essentially, the escalation pathway if the most senior neonatologist/pediatrician is unable to stabilize the neonatal airway including involving ENT surgeons (68), pediatric respiratory specialists or consultant anesthesiologist with airway expertise, should exist formalized in policies and procedures tailored to the individual context.
Simulation and Practice
The ERC Newborn Life Back up guidelines (2) emphasize airway management as the fundamental component of neonatal stabilization and/or resuscitation at birth. Awareness has increased regarding the importance of human factors, including crew resource management (CRM) and systems optimization for successful training in dealing with the difficult airway situation (29). Simulation training to acquire and maintain skills, and practicing not-technical skills including communication, CRM and leadership are recommended (70, 71). Implementation is also a major consideration being more than only simulation and practise and must be washed thoroughly and so that all involved doctors can acquire the designated steps in the suggested algorithm. Communication according to CRM principles and the method of "airtight loop" communication together with team members having defined roles and function, is current practise at AUH.
Discussion
In older children, a hard airway situation arises more frequently at intubation for surgery, i.e., in a controlled and well-equipped surroundings with an airway skilful nowadays. In the neonate, including in the DR, the need for intubation is more than often unexpected. The rate of three or more than intubation attempts in our DR observations was 65%. 4 out of 20-iii patients (17%) were not intubated despite multiple attempts at securing the airway, and in 11 (48%) patients, three or more attempts were needed to achieve successful ETI. In a multicenter NICU intubation registry (12), a difficult airway situation, defined as the need for three or more attempts, occurred in xiv% of patients, considerably less than what we observed in our hospital.
Guidelines for difficult airway management in older children and adults include the Difficult Airway Club 2015 guidelines for adults and children (29), and recommendations from airway focus groups and societies (x, 72–74). Similar guidelines for children also exist (59, sixty, 75, 76) and these are used daily in countries all over the world. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Baby (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the DR and NICU. After our DR observations, still no algorithm exists in our unit, while a Karl Storz CMAC videolaryngoscope has been purchased. However, there is no guideline to advise in which situations the VL should be used.
Based on our literature review, stylets and bougies, in combination with videolaryngoscopy may potentially have improved the success charge per unit of ETI in the hard airway situations in our DR. Even so, use of neonatal bougies remains controversial. An LMA could have been used if ETI was unsuccessful. Based on a remarkably high incidence of a hard airway situation in the DR and a literature review, we advise a unproblematic management-algorithm for the neonatal unanticipated difficult airway (Figure ii).
Effigy ii. Proposed algorithm for the management of the neonatal unanticipated hard airway. The blood-red column describes the situation where mask ventilation is hard and/or impossible to achieve despite measures including the insertion of an oropharyngeal or nasopharyngeal tube, and ii-person mask ventilation. The crimson cavalcade is the most fourth dimension critical. The blueish column is the situation where mask ventilation is possible, but the newborn is difficult to intubate, e.chiliad., a semi-vigorous baby where positive pressure ventilation is considered ineffective or prolonged. In this situation there is commonly time to reevaluate the initial management program and reposition the head of the newborn for another intubation try with a videolaryngoscope. DR, Delivery Room; FONA, Forepart of neck access; NICU, Neonatal intensive care unit; SAD, Supraglottic airway device.
The main goals of the algorithm are to minimize intubation attempts, apace achieve adequate oxygenation and ventilation, and institute a definite airway by either the insertion of a LMA or successful ETI. Calling for help early on and making sure that the most competent airway provider is present is crucial. Importantly, to optimize intubation conditions, pre-medication and muscle relaxants should be given whenever time allows information technology. FONA is technically difficult in neonates and should simply be performed past ENT surgeons.
The algorithm is elementary in order to be intelligible in a time-critical and stressful state of affairs. Just also, for the suggested algorithm to inform and meliorate practice it should be learned and trained in simulations and under supervision in real-life situations. A hard airway and intubation can occur anywhere and at any time of the solar day or dark, and the algorithm is not site-specific for apply simply in the DR or NICU. The crimson and bluish columns can too exist a consequence of one another. For example, if mask ventilation is possible while intubation is difficult, the assistants of analgesics and muscle relaxants may issue in a "no longer able to ventilate" situation while intubation is yet difficult. In such a situation, measures to attain successful ETI must exist performed faster while the situation becomes more stressful.
Limitations of our empirical data are present. The raw data video recordings were non available as all videos were, for confidentiality reasons, erased after initial review and transcription. This is the master reason why more details of the intubation attempts are lacking, e.g., the causes for the multiple failed intubation attempts. Extremely pre-term neonates from 22 to 27 + six weeks gestation are more likely to present major difficulties during mask ventilation and intubation due to their small size and more unstable status in general, but are underrepresented in our cloth.
In conclusion, based on our observations of DR resuscitations and a review of the literature, we suggest a "neonatal difficult airway algorithm" that includes limiting individual provider ETI attempts and use of airway adjuncts. Our recommendations as well include practice and preparations for the non-technical requirements of dealing with the stress of an unexpected difficult airway.
Data Availability Statement
The raw information supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics Argument
The studies involving human participants were reviewed and approved by the Norwegian Health Directorate (HDIR) and Klinisk Etisk komite (REK) at Akershus University Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the minor(southward)' legal guardian/adjacent of kin for the publication of any potentially identifiable images or data included in this article.
Author Contributions
GB and AS conceptualized and designed the report, performed data assay and interpretation, and drafted the initial version of the manuscript. AB performed the information drove, structured the information, and was involved in the data analysis and interpretation. EB and AR were involved in the data analysis and interpretation. All authors participated in critical revision of the manuscript for important intellectual content and approved the final manuscript equally submitted and concur to be accountable for all aspects of the piece of work.
Funding
This research was supported past the Laerdal Foundation for Acute Medicine, Stavanger, Norway.
Conflict of Involvement
The authors declare that the research was conducted in the absence of whatever commercial or financial relationships that could be construed every bit a potential conflict of involvement.
Publisher's Note
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