CLINICAL PRACTICE © 2012 SNL All rights reserved 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. 116 VOLUME 8 ISSUE 4 2012 infant CLINICAL PRACTICE 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