Managing the Newborn Infant with a Difficult Airway

Managing the newborn infant with a difficult airway

Airway management is a core skill in neonatology and proficiency in managing the difficult airway may be life-saving in an acute emergency. In the following article the authors outline a three-step intervention which aims to improve neonatal airway management within the Southern West Midlands Newborn Network. It encompasses a structured skills training programme in airway management combined with simple guidelines, to enable rapid decisions to be made at times of crises. Frequent reinforcement of such training should lead to skill retention, improved knowledge, a boosting of confidence and may improve patient outcomes.

Lauren C Johansen1 t birth, 5-10% of all infants will require If the infant has a craniofacial 1 MBBS (Hons), MRCPCH, Specialist Registrar Aassisted ventilation . The rapid abnormality, management of the airway in Paediatrics. [email protected] provision of effective positive pressure may become even more difficult and ventilation is the single most important challenging (see TABLE 1). It is most Richard H Mupanemunda1 predictor of successful neonatal important therefore that as trainees’ BSc BM MSc FRCPCH, Consultant resuscitation2. Ineffective ventilatory opportunities for training are reduced, Neonatologist support leads to hypoxia and may result in structured training programmes to teach

2 increased morbidity and mortality. essential and potentially life-saving Ratidzo F Danha Endotracheal intubation of newborn procedural skills such as intubation are MBChB MMed FCARCSI, Consultant infants is a skilled procedure performed provided as part of the core training in Paediatric Anaesthetist most often by advanced neonatal nurse neonatal medicine. 1NICU, Heartlands Hospital, Heart of England practitioners, paediatric trainees and other NHS Foundation Trust, Birmingham non-career grade practitioners. Although ■ Achondroplasia competency in the intubation of newborn ■ Beckwith Wiedemann syndrome 2Anaesthesia Dept, University Hospitals infants, including extremely premature ■ Cleft palate Coventry and Warwickshire NHS Trust babies and those with congenital ■ Craniofacial dysostosis: Apert, Crouzon malformation, is a requisite for completion and Pfeiffer’s syndromes of the RCPCH curriculum in neonatal Keywords ■ Cystic hygroma medicine, training in airway management ■ Down’s syndrome difficult airway; indirect laryngoscopy; tends to be opportunistic and the ■ endotracheal intubation; laryngeal mask individual experience of paediatric trainees Fibrodysplasia ossificans progressiva airway; newborn infants; training ■ is often variable. Furthermore, during the Freeman-Sheldon syndrome Key points last decade the requirements of ■ Goldenhar syndrome Modernising Medical Careers3 and the ■ Hemi facial microsomia Johansen L.C., Mupanemunda R.H., Danha European Working Time Directive4 have ■ Klippel-Feil anomaly R.F. Managing the newborn infant with a combined to reduce both the time ■ difficult airway. Infant 2012; 8(4): 116-19. Laryngeal cysts 1. A structured training programme in postgraduate trainees spend in their ■ Mandibulofacial dysostosis training programmes and their working airway management is needed for ■ Mucopolysaccharidoses hours and subsequently substantially trainees to achieve competency in ■ Pierre Robin sequence essential procedural skills. reduced their opportunities for experiential ■ Rubenstein-Taybe syndrome 2. The presented guideline for difficult learning and training. In medicine there is ■ airway management in the newborn a large body of evidence showing a Treacher-Collins syndrome enables rapid decisions to be made in correlation between expertise and ■ Vascular malformations: times of crises. experience5,6 and not surprisingly, today’s haemangioma/ arteriovenous malformations involving the face or 3. Indirect laryngoscopy is the gold trainees are less experienced than trainees airway standard for managing difficult from earlier generations with some reports ■ Venous lymphatic malformation endotracheal intubation. indicating that third year paediatric 4. Video laryngoscopy enhances trainees failed in their attempts to intubate TABLE 1 Craniofacial anomalies that may intubation training by facilitating infants within two attempts in up to 40% compromise the airway in the newborn visualisation of airway anatomy. of cases7. period8,9.

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Apnoeic infant or infant with inadequate respiratory effort

• Neutral head position • Ensure the facemask is the correct size Good facemask T-piece ventilation Facial abnormalities causing poor • Apply a two-handed jaw thrust but infant still needs ventilatory mask fit and inadequate ventilation • Useful adjuncts include oropharyngeal assistance and nasopharyngeal airways

Insert a size 1 laryngeal mask airway Failed LMA Return to facemask Failed Prepare for intubation with a Miller (Infant >1.5kg) and ventilate through T-piece ventilation intubation laryngoscope: this device. Secure with tape to avoid • Maximum two attempts per dislodgement. person • No more than four intubation CALL FOR SENIOR HELP The laryngeal mask (LMA) is a attempts and ventilate in dedicated airway and can be used to between attempts ventilate until expert help arrives.

Consider two further intubation attempts by senior trainee or neonatologist and if this fails

CALL FOR EXTERNAL HELP

• Video laryngoscope or flexible fibrescope - assisted intubation by an anaesthetist • ENT surgeon can perform rigid bronchoscopy; insert a bougie and rail-road endotracheal tube • Surgical tracheostomy as last resort

FIGURE 1 Difficult airway management in the newborn.

Currently there is no standard UK Can’t ventilate adequately, can’t intubate airway adjunct may be particularly useful protocol for the management of a difficult If on initial assessment the infant is in the management of infants with Down’s neonatal airway and many neonatal units apnoeic or has inadequate respiratory syndrome in whom hypotonia may cause do not stock the equipment required for effort then the resuscitator must attempt to posterior tongue displacement. A advanced airway techniques. In addition, deliver positive pressure ventilation. The nasopharyngeal airway may be used to none of the hospitals that deliver babies in infant’s head should be placed into the relieve upper airway obstruction in infants the Southern West Midlands Newborn neutral position. A correctly sized face with Pierre-Robin sequence, craniofacial Network have a dedicated paediatric mask should be positioned, encircling the anomalies and micrognathia. As neonatal anaesthetist on site at all times to offer infant’s mouth and nose and inflation nasopharyngeal airways are not expert support if an emergency arises. The breaths should be delivered using the commercially available, a shortened authors feel strongly that these issues need T-piece. If there is difficulty creating a tight endotracheal tube (ETT) may be used. The to be addressed as, although rare, the ‘can’t seal on the face-mask a two-handed jaw required nasopharyngeal airway length can ventilate adequately, can’t intubate’ thrust should be applied with the help of a be estimated from the distance between the scenario is life threatening. Morbidity and second healthcare professional. nasal tip and the tragus of the ear. The mortality is associated with repeated If facemask T-piece ventilation remains airway should be lubricated and passed intubation attempts when airway oedema inadequate an airway adjunct should be through the nostril, posteriorly along the can result in a ‘can’t ventilate, can’t used. The oropharyngeal airway (Guedel floor of the nose into the pharynx. A intubate’ scenario. Therefore in the airway) is available in a variety of sizes for correctly sized nasopharyngeal airway will following article a programme to improve infants and can help maintain a patent fit snugly in the nostril without causing neonatal airway management within the airway channel between the tongue and the blanching of the alae nasi10. Southern West Midlands Newborn posterior pharyngeal wall, by displacing the If the resuscitator is still unable to Network is proposed. tongue anteriorly. It is important to size oxygenate the infant, as seen by poor chest movement, cyanosis or bradycardia they Step 1: Establishing a difficult the oropharyngeal airway correctly: too small an airway is ineffective and may must call for senior help. At this stage, a airway management algorithm for worsen airway obstruction and too large an supraglottic airway may be used for airway newborn infants airway may cause laryngospasm. If the rescue if bag and mask ventilation has The proposed Difficult Airway airway is the correct size the tip should failed11. It is an effective modality for Management Algorithm for Newborn reach the angle of the jaw when the flange ventilation and studies have shown Infants is illustrated in FIGURE 1. is aligned with the centre of the lips10. This laryngeal mask airways (LMAs) to be quick infant VOLUME 8 ISSUE 4 2012 117 CLINICAL PRACTICE and easy to insert12. Gandini’s prospective additional attempts to intubate the infant ■ Infant oropharyngeal airways observational study reported successful using a video laryngoscope. Indirect ■ Infant nasopharyngeal airways resuscitation and ventilation of 103 laryngoscopy is the gold standard for ■ Infant laryngeal mask airways newborn infants using an LMA and of managing difficult endotracheal ■ Introducers these newborns 29 were low birthweight, intubation, especially in the case of ■ Endotracheal tubes ranging from size with six weighing between 1000 and 1499 craniofacial abnormalities. Studies have 2-4.5 grams13. However, although several infant shown that video laryngoscopy improves ■ Endotracheal tube fixation equipment LMA devices are now available their the glottic view in children when ■ Miller laryngoscope and blades usefulness remains limited in extreme compared to direct laryngoscopy17,18. There ■ Storz C-Mac video laryngoscope premature infants due to their size. If LMA are currently four devices that can be used ■ Miller 0 and Miller 1 blades for the insertion is successful the infant should be in children under the age of two; the C-Mac Storz video laryngoscope ventilated through the LMA and Airtraq disposable optical laryngoscope, FIGURE 3 Difficult neonatal airway transferred to the neonatal unit for the Glidescope video laryngoscope, equipment set. intubation by a senior neonatologist. Truview PCD Infant and the Storz DCI If LMA insertion is unsuccessful the video laryngoscope (SVL)19 (FIGURE 2). The this technique is also unsuccessful then resuscitation team should prepare for SVL has the shortest blade and therefore expert help from an ENT surgeon or intubation. The infant should be can be used in small preterm infants with paediatric anaesthetist should be sought, to appropriately positioned. A roll under the limited mouth opening; as demonstrated enable a life-saving surgical tracheostomy shoulders may be helpful but over- by Vanderhal et al who reported 48 or rigid bronchoscopy to be performed. extension of the neck should be avoided. successful intubations in infants ranging A straight bladed Miller laryngoscope is from 530 to 6795g20. Step 2: Preparing a difficult airway preferred in infants as its narrow tip can If indirect laryngoscopy is unsuccessful equipment set help lift the epiglottis to expose the vocal immediate expert help should be sought. An easy to access, well-maintained difficult 14 cords . Gentle external cricoid pressure Notably the cricothyroid space is too small airway trolley is integral to the successful may further help to drop the vocal cords to cannulate in neonates and so a surgical delivery of expert neonatal airway into view. Once a clear view of the vocal cricothyrotomy is not a suitable procedure management. The trolley should be kept in cords is obtained the ETT should be in this age group. A paediatric ENT a specially allocated area to ensure rapid inserted from a lateral approach. An surgeon may perform rigid bronchoscopy retrieval when it is required. Drawers introducer may be helpful if there are and may use an introducer placed in the should be arranged with increasing difficulties in guiding the ETT through trachea to facilitate intubation by rail- invasiveness from top to bottom. An the cords. roading an ETT, if video laryngoscopy has equipment checklist should be attached to If direct laryngoscopy proves difficult it failed. An ENT surgeon may perform a the trolley, and a staff member should be is important to limit the number of life-saving surgical tracheostomy if all the designated to check and restock the trolley attempts made in order to reduce the risk above measures have failed. on a daily basis. Sterility, cleaning and of upper airway trauma, oedema and maintenance instructions should be stored bleeding. Therefore it is suggested that each Can ventilate, can’t intubate with the equipment and these should be person should have a maximum of two If on initial assessment facemask T-piece closely adhered to, to ensure longevity and attempts at intubation and no more than ventilation is effective, as demonstrated by maximal performance of the equipment. four attempts should be made in total. This good chest expansion and a rising heart Suggested equipment for a difficult airway guidance is in line with the Difficult rate, but the infant still needs assistance set is displayed in FIGURE 3. Airway Society’s adult algorithms15,16. If then the resuscitator should prepare for intubation is successful the infant should intubation. Step 3: Improving training in be transferred to the neonatal unit for Each intubation attempt should be intubation and difficult airway further stabilisation. limited to 30 seconds to minimise the risk Where direct laryngoscopy has failed, the of hypoxia. If the intubation attempt is management assistance of the most experienced neo- unsuccessful then the resuscitator should Standard teaching of direct laryngoscopy natologist should be sought. A return to facemask T-piece ventilation to can be problematic. It is difficult to give a neonatologist or anaesthetist experienced optimise oxygenation. Each person should practical demonstration of the neonatal in the use of videolaryngoscopy may make have a maximum of two attempts at intub- airway anatomy and the intubation process ation, with no more than four attempts to a learner, while carrying out the being made in total. This limits trauma to procedure, and standing to one side to the airway which could convert a ‘can allow the trainee a hasty view of the vocal ventilate, can’t intubate scenario’ into the cords is not ideal. Furthermore providing life threatening ‘can’t ventilate, can’t intub- supervision and assistance to the inexper- ate’ scenario. If intubation is unsuccessful ienced trainee can be challenging because consider inserting an LMA as a rescue one is wholly reliant on the trainee’s ability device and ventilating through the device. to give feedback on what they can see If both direct laryngoscopy and LMA through the laryngoscope, and providing insertion fail, indirect laryngoscopy should an accurate description can be difficult for FIGURE 2 The Storz DCI video laryngoscope. be used to attempt intubation. However, if trainees with limited experience.

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Recent studies have shown that video training programme will be offered to A cognitive perspective on medical expertise: theory laryngoscopy enhances intubation training other neonatal trainees within the region and implications. Acad Med 1990;65:611-21.2003. by facilitating visualisation of airway as part of their formal training in neonatal 7. Falck A.J., Esobedo M.B, Baillargeon J.G. Proficiency of pediatric residents in performing neonatal endo- anatomy; this subsequently improves medicine. At a later stage, the programme tracheal intubation. Pediatrics 2003;112:1242-47. performance and promotes increased will be available to other healthcare staff, 8. Vashit M., Miglani H.P.S. Approach to difficult and trainee confidence levels21,22. The design of including non-career grade paediatricians, compromised airway in neonatal and paediatric age the SVL allows for improved training in physician assistants and advanced neonatal group patients. Indian J Anaesth 2008;52:273-81. both direct and indirect videolaryngo- nurse practitioners. 9. Waage N.S., Baker S., Sedano H.O. Pediatric conditions associated with compromised airway: scopy. It can be used as a conventional Hopefully these studies will contribute to part 1 – congenital. Pediatr Dent 2009;31:236-44. Miller laryngoscope; with its 14 x 25cm the growing evidence on the utility of both 10. Advanced Life Support Group. Mackway-Jones K., monitor screen enabling colleagues to see direct and indirect video laryngoscopy in Molyneux E., Phillips B., et al, eds. Advanced the operator’s view of the glottis19. This can training neonatal specialists to manage the support of the airway and ventilation. Advanced advance trainees’ understanding of upper airways of infants requiring respiratory Paediatric Life Support The Practical Approach. airway anatomy prior to them attempting support, leading to this scheme being Fourth Edition. 2005, 37-46. 11. Grein A.J., Weiner G.M. Laryngeal mask airway the procedure themselves. Moreover the adopted nationally. versus bag-mask ventilation or endotracheal supervisor can provide trainees with better intubation for neonatal resuscitation (review). The guidance during the intubation, and can Conclusion Cochrane Collaboration. 2009. see for themselves the effectiveness of a Neonatal trainees need to acquire several 12. Trevisanuto D., Micaglio M., Pitton M. et al. change in position or the application of procedural skills during their training. Laryngeal mask airway: is the management of neonates requiring positive pressure ventilation at cricoid pressure. Airway management is one such core skill birth changing? Resuscitation 2004;62:151-57. An audio-video teaching package is and proficiency in managing the difficult 13. Gandini D., Brimacombe J.R. Neonatal resuscitation currently under development in the Heart airway may be life-saving in an acute with the laryngeal mask airway in normal and low of England Foundation Trust, to support emergency. The recent introduction of birth weight infants. Anaesth Analg 1999;89:642-43. the video laryngoscopy training shorter training periods for UK 14. Lofosino A. Pediatric upper airway and congenital anomalies, Anesthesiol Clin North America programme. The aim is to aid senior postgraduate medical and surgical trainees 2002;20:747-66. paediatric trainees and consultants in the along with the reduction in working hours 15. Heidegger T., Gerig H.J., Henderson J.J. Strategies for development of indirect laryngoscopy skills due to the Working Time Regulations, management of the difficult airway. ASEAN and increase their ability to manage the makes a strong case for the provision of a J Anaesthesiol 2011;12:56-62. difficult neonatal airway. structured programme in airway 16. Difficult Airway Society. Difficult Airway Society Research has demonstrated that gaining management in order for trainees to guidelines: strategy for intubation by direct laryngoscopy, no predicted airway problem, no risk of experience in what has been learnt is an achieve proficiency in essential procedural regurgitation. www.das.uk.com/guidelines/ddl.html. integral step in the acquisition of skills. Skills training in airway management [Online] 2004. knowledge23. Furthermore for the with simple guidelines enable rapid 17. Vlatten A., Aucoin C., Litz S. et al. A comparison of successful incorporation of a new decisions to be made at times of crises and the STORZ video laryngoscope and standard direct technique into clinical practice the the frequent reinforcement of such laryngoscopy for intubation in the pediatric airway- a randomized clinical trial. 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