Emergency airway management in paediatrics

Overview

This clinical practice guideline from the Royal Children's Hospital Melbourne, last updated in March 2021 and endorsed by the Paediatric Improvement Collaborative, sets out how to manage the airway of a child who needs emergency intubation. In emergencies, problems are rarely caused by anatomically difficult airways and more often by physiological or situational difficulty, such as operator experience or staffing. The strongest predictors of adverse events are multiple intubation attempts and respiratory or cardiovascular failure as the reason for intubation.

Preparation

Physiology is optimised before induction: the head of the bed is raised (up to 40 degrees), the child is pre-oxygenated with positive airway pressure or PEEP, and apnoeic oxygenation by nasal cannula can be added. An attempt is stopped if saturation falls below 93% or drops by 10% from baseline. Hypotension is treated with fluid (10 to 20 mL/kg) and push-dose adrenaline in a non-arrested child, which is not the same as the cardiac arrest dose. The airway is assessed for expected difficulty, including congenital syndromes, trauma, burns, airway debris and inhaled smoke, and help is called early if there are concerns, before any medication is given.

Equipment, drugs and team

Equipment is laid out on an airway template, monitoring includes saturation, heart rate, respiratory rate, blood pressure and ETCO2, and a pre-intubation checklist is read aloud in challenge-response form by the team leader, with reassessment after any failed attempt. Ketamine is the preferred default induction agent for most emergency intubations and rocuronium the default muscle relaxant. All induction agents can cause hypotension in unwell children, so doses are reduced. Cricoid force is not routinely used because it can compress the trachea and make oxygenation and intubation harder.

Confirming tube position

No single method is 100% reliable. The best indicators are direct visualisation of the tube passing through the cords and continuous waveform capnography. If the cords cannot be seen, the tube should not be passed: the child is reoxygenated and another attempt is planned with a different intubator, position or technique. If the ETCO2 waveform is lost or the child arrests, the child is reassessed, resuscitation begins and the tube is checked, and it is removed if placement is uncertain. Auscultation, chest rise, misting and pulse oximetry are less reliable, a chest X-ray shows only depth, and point-of-care ultrasound can help.

After intubation

The tube is secured, its position is reconfirmed and ongoing sedation is started. A plan for a cannot-intubate-cannot-oxygenate (CICO) emergency is part of every intubation, and a short debrief afterwards helps to identify technical and human factors. Transfer is considered when no facility to manage intubated children is available locally.