Upper Airway Obstruction in a Child
OVERVIEW
This is an airway emergency with upper airway obstruction in a paediatric patient.
AN APPROACH
Call for help!
- assess whether intubation needs to take place now
- if patient is still breathing – keep them breathing and transfer to OT for inhalational induction with most experienced with the paediatric airway
- if patient is not breathing – attempt bag-mask ventilation with 100% O2 and attempt intubation now
- paediatric anaesthetist
- paediatrician
- ENT surgeon
- notify theatre
Optimise
- O2 (can hold mask away from face if distressing)
- keep child calm (allow to stay in parents arms, EMLA for IV access)
- adrenaline nebuliser (5mg)
- dexamethasone 0.6mg/kg IV
- oxygen/helium mixture if tolerates
Monitoring
- ECG
- SpO2
- NIBP
- ETCO2 ready
- RR
- work of breathing
Equipment and Drugs
- Weight = age + 4 x 2 = 12kg
- Selection of laryngoscopes – size 1 – 3, (straight and curves)
- Selection of guedels
- Selection of ETT – age/4 +4 = 4.5 but will need smaller tube given upper airway obstruction (3.5, 4.0, 4.5, oral and nasal, uncuffed)
- LMA – #1.5 and #2
- Bougie
- Stylet
- Bag-mask
- Suction
- Trans-tracheal airways
- Volatile anaesthetic agents – sevoflurane
- IV induction agents – propofol 3-4mg/kg, thiopentone 3mg/kg
- Muscle relaxants – suxamethonium 1-2mg/kg IV
- Resuscitation drugs – atropine 25mcg/kg, adrenaline 0.1mL/kg of 1:10,000, metaraminol increments
- Fluids – N/S 10-20mL/kg boluses
Technique
- Inhalational induction in OT with scrubbed ENT surgeon ready to secure a trans-tracheal airway, OR
RSI if child in extremis
Failure
- Keep child spontaneously breathing as long as possible
- Bag-mask +/- Guedel or nasal ETT
- LMA insertion
- Cricothyroidotomy/Tracheostomy
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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