Overview
Definition:
A difficult airway cart in pediatrics is a pre-assembled collection of specialized equipment and medications designed to facilitate rapid and effective airway management during emergent intubation in infants and children
It aims to provide readily accessible tools for both anticipated and unanticipated difficult airway scenarios, thereby minimizing the risks of hypoxia and adverse outcomes.
Epidemiology:
Difficult intubation occurs in approximately 1-10% of pediatric patients, with higher rates in neonates and those with specific congenital anomalies or syndromes
The incidence of failed intubation requiring immediate rescue maneuvers is significantly lower but carries high morbidity and mortality
This underscores the importance of preparedness.
Clinical Significance:
Effective airway management is a cornerstone of pediatric critical care and emergency medicine
A well-stocked and organized difficult airway cart ensures that clinicians can swiftly address challenging intubation scenarios, reducing the time to secure the airway, minimizing oxygen desaturation, and preventing severe complications such as hypoxemic brain injury, aspiration, and cardiac arrest
It is crucial for resident preparedness for DNB and NEET SS examinations.
Cart Components
Basic Equipment:
Laryngoscopes (different sizes, including premature and infant blades like Miller 0-1 and Macintosh 1-2)
multiple endotracheal tubes (ETT) of various sizes (e.g., 2.0-7.0 mm internal diameter, uncuffed and cuffed)
introducers/stylets
lubricant
securing devices (tape, commercial holders)
oral and nasal airways (appropriate sizes).
Advanced Devices:
Suction catheters and wall suction
bag-valve-mask (BVM) with appropriately sized masks (infant, pediatric, adult)
a cricothyrotomy kit (needle or surgical)
video laryngoscope (e.g., C-MAC, Glidescope with pediatric size blades)
supraglottic airway devices (e.g., LMA, i-gel in various pediatric sizes)
fiberoptic bronchoscope (if available and personnel trained)
esophagoscopy/intubation detection devices.
Pharmacological Agents:
Sedatives (e.g., midazolam, ketamine, propofol)
paralytics (e.g., succinylcholine, rocuronium – with consideration for pediatric indications and contraindications)
analgesics (e.g., fentanyl)
vasopressors (e.g., epinephrine, dopamine)
atropine
sodium bicarbonate
emergency medications for potential complications (e.g., amiodarone).
Adjuncts And Supplies:
Oxygen source and tubing
capnography device (essential for confirmation of ETT placement)
intubating bougie
gum elastic bougie
small bore feeding tubes for suctioning
towels/rolls for head positioning (sniffing position)
sterile gloves
personal protective equipment (PPE).
Preparation And Organization
Layout And Accessibility:
The cart should be organized logically with frequently used items easily accessible
Medications should be clearly labeled, checked for expiration dates, and stored appropriately
Compartments or drawers can be used to group similar items (e.g., laryngoscope blades together, ETTs by size).
Regular Inventory Checks:
Scheduled weekly or bi-weekly checks to ensure all items are present, functional, and within their expiration dates
Deficiencies should be immediately restocked
This is critical for emergency preparedness and a key exam point.
Staff Training And Familiarity:
All healthcare providers involved in pediatric resuscitation should be trained on the cart's contents and organization
Regular simulation drills practicing difficult airway algorithms using the cart are essential for competency and confidence
Understanding the equipment is vital for DNB and NEET SS.
Pediatric Considerations
Anatomical Differences:
Pediatric airways differ significantly from adults: larger head relative to body, prominent occiput requiring head elevation (sniffing position), larger tongue, floppier epiglottis, higher larynx (more anterior), and narrowest point at the cricoid cartilage in infants
These factors influence laryngoscope blade choice and intubation technique.
Pharmacological Dosing:
Pediatric drug doses are weight-based and require careful calculation
Knowledge of appropriate induction, paralytic, and rescue medication doses is paramount
Emergency drug charts and calculators should be readily available.
Age Specific Risks:
Neonates and infants have higher metabolic rates and smaller functional residual capacity (FRC), leading to rapid desaturation
Congenital anomalies (e.g., Pierre Robin sequence, Treacheris coli, Down syndrome) increase the risk of difficult airways
Specific syndromes may contraindicate certain drugs like succinylcholine.
Algorithms And Protocols
Initial Assessment:
Assess for signs of difficult airway (e.g., difficult mask ventilation, difficult laryngoscopy, difficult intubation history, patient anatomy)
Use established algorithms like the P.L.A.N
(Mask Ventilation Plan, Airway Access Plan, Nitrogen Plan) or the WHO difficult airway algorithm.
Intubation Attempts:
Limit intubation attempts to avoid trauma and hypoxia
If initial attempts fail, consider alternative devices or techniques
Have a clear plan for when to abandon intubation and proceed to rescue airway management.
Rescue Airway Strategies:
If intubation fails, rapidly transition to a rescue strategy, which may include supraglottic airways, or surgical airway (cricothyrotomy or tracheostomy) if indicated and feasible
Video laryngoscopy and bougie use are key first-line adjuncts.
Confirmation Of Placement:
Always confirm endotracheal tube placement using multiple methods: direct visualization of ETT passage, capnography (gold standard), chest rise, breath sounds, and absence of air entry into the stomach
This is a critical exam concept.
Key Points
Exam Focus:
Key exam areas include components of the cart, anatomical differences in pediatric airways, age-appropriate drug dosages, confirmation of ETT placement using capnography, and the step-by-step approach to difficult airway algorithms
Understanding the rationale behind equipment selection is crucial.
Clinical Pearls:
Always have a backup plan and backup equipment
Pre-oxygenation with 100% oxygen for at least 3-5 minutes is vital
Secure the airway early if difficulty is anticipated
Never assume airway patency
Practicing with the cart during mock codes enhances team performance.
Common Mistakes:
Using the wrong size equipment
Inadequate pre-oxygenation
Excessive or repeated intubation attempts leading to hypoxia and trauma
Failure to confirm ETT placement adequately
Delays in initiating rescue airway maneuvers
Incorrect drug dosages
Forgetting the importance of positioning the patient (sniffing position).