Paediatric anaesthesia
-
It has been traditionally taught that only uncuffed endotracheal tubes (ETTs) should be used for intubation in children younger than 8, or even 10, years old. However, recent literature suggests that the advantages of using uncuffed ETTs in children may be just another myth of paediatric anaesthesia. ⋯ Longer duration of intubation and a poorly fitted ETT are risk factors for mucosal damage, whether the ETT is cuffed or uncuffed. Furthermore, a properly sized, positioned, and inflated modern (low-pressure, high-volume) cuffed ETT can offer many advantages over an uncuffed ETT, including greater ease of intubation, better control of air leakage, lower rate and better control of flow of anaesthetic gases, and decreased risk of aspiration and infection.
-
Compression of the paediatric airway is a relatively common and often unrecognized complication of congenital cardiac and aortic arch anomalies. Airway obstruction may be the result of an anomalous relationship between the tracheobronchial tree and vascular structures (producing a vascular ring) or the result of extrinsic compression caused by dilated pulmonary arteries, left atrial enlargement, massive cardiomegaly, or intraluminal bronchial obstruction. A high index of suspicion of mechanical airway compression should be maintained in infants and children with recurrent respiratory difficulties, stridor, wheezing, dysphagia, or apnoea unexplained by other causes. ⋯ Vascular rings may be repaired through a conventional posterolateral thoracotomy, or utilizing video-assisted thoracoscopic surgery (VATS) or robotic endoscopic surgery. Persistent airway obstruction following surgical repair may be due to residual compression, secondary airway wall instability (malacia), or intrinsic lesions of the airway. Simultaneous repair of cardiac defects and vascular tracheobronchial compression carries a higher risk of morbidity and mortality.
-
Cricoid pressure to occlude the upper end of the oesophagus, also called the Sellick manoeuvre, may be used to decrease the risk of pulmonary aspiration of gastric contents during intubation for rapid induction of anaesthesia. Effective and safe use of the technique requires training and experience. Cricoid pressure is contraindicated in patients with suspected cricotracheal injury, active vomiting, or unstable cervical spine injuries. ⋯ The recommended pressure to prevent gastric reflux is between 30 and 40 Newtons (N, equivalent to 3-4 kg), but pressures greater than 20 N cause pain and retching in awake patients and a pressure of 40 N can distort the larynx and complicate intubation. The recommended procedure is, therefore, to induce anaesthesia and apply a pressure of about 30 N, either manually or with the cricoid yoke, to facilitate intubation. Reported complications of cricoid pressure during intubation include oesophageal rupture and exacerbation of unsuspected airway injuries.
-
Airway management skills are integral to the practice of anaesthesiology and also to the practice of emergency medicine and allied health professions such as respiratory care, emergency medical technology, and emergency and critical care nursing. The basic information to be taught is the same but the level of detail will vary depending on the audience. ⋯ Modalities that may be used for skills training include cadavers, recently dead patients, videotapes, mannequins, simulators and virtual reality trainers. To maintain knowledge and skills, review and possible retraining should be conducted on an approximately annual basis.
-
Although difficult airway management remains one of the leading factors in anaesthetic deaths, there have been tremendous advances in the field in the last few decades. The question is, are advanced airway management skills being taught and used? Of the numerous training tools available, simulators have the advantages of providing whole-task learning with the potential to change behaviour and, when applied to large groups of trainees, the possibility of achieving standardized application of the safest practices for a range of scenarios limited only by the creativity of the program designers. Partial-task trainers include computer-based software programs and simulators. ⋯ This can best be achieved through a dedicated airway management rotation. Monitored procedure logs may also be used. Whether using a simulator or in a clinical rotation, experiences should be graded, for example, gaining experience in an adult population before gaining experience in paediatrics and in each population mastering airway management skills for common scenarios before advancing to more complicated techniques such as fibreoptic bronchoscopy.