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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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