Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now?

The Head and Neck surgeon was able to use his fiberscope to take a quick look at the child’s upper airway. Although the epiglottis and pharynx was swollen, he was able to see that the vocal cords themselves appeared normal, implying that the burn from the detergent was oropharyngeal and most likely not tracheal. This was an important distinction since a tracheal burn from aspirating the detergent might cause progressive lower airway edema and loss of the airway. Since this appeared to be oropharyngeal, they felt justified in initially treating this medically, without intubation, especially since racemic epinephrine had improved the stridor.

Managing Fixed Airway Obstruction

The most common emergencies involving airway obstruction include epiglottitis, croup, foreign body, trauma, and tumor. Epiglottitis, croup, and foreign body are more common in the pediatric population. In this case, airway edema was not infectious but caustic exposure.

Airway obstruction is a life-threatening emergency. If you’re an inexperienced intubator, you should seek the advice of any available experienced intubators. Multiple prolonged or traumatic intubation attempts may worsen existing airway obstruction by causing bleeding and increasing edema, leading to a potentially fatal situation. When we can, we often bring such patients to an operating room where they are either intubated awake if adults or under deep inhalational anesthesia with spontaneous ventilation if a child. Children won’t typically tolerate an awake intubation. The personnel and means to perform emergency tracheostomy are immediately available and ready. Have plenty of help available.

Don’t subject a child to unnecessary laboratory exams, or separate him prematurely or unnecessarily from parents. Crying and screaming increases airway edema. Keep him calm. Don’t sedate him. Sedation may cause him to lose what airway tone he has. Placing the parent in a wheelchair with the child in the parent’s lap may be the best choice for transporting a frightened child with airway obstruction around the hospital setting.

If your patient  is breathing more comfortably sitting up allow him to do so, as long as vital signs are stable. A patient who is sitting has a larger functional residual capacity than one lying down — about 1 liter larger in the adult. A larger FRC provides a larger volume for oxygen exchange. When a compromised patient lies down, soft tissue in the oropharynx tends to collapse over the airway, possibly increasing obstruction. Elevating the head may slow development of any edema.

Give supplemental oxygen, humidified if possible to minimize irritation from dry gases. If the patient must be sent to another location, ensure that someone who can manage airway obstruction accompanies them. This intubator must take all required airway equipment with him or her.

Racemic Epinephrine

Racemic epinephrine, as was used here, can be a very effective agent for reducing airway swelling. The dose is:

  • Racemic Epinephrine (2.25%)
  • dilute in 2 ml of normal saline to nebulize
  • Dose: 0.05 ml/kg (maximum 0.5 ml in children)
  • Child under 6 months: 0.25 ml
  • Child: 0.5 ml
  • Adolescent: 0.75 ml

Onset is usually within 20 minutes and the effects last about 90 minutes. Decompensation, for example from a diagnosis like croup, typically occurs within 1.5 hours, therefore you should observe the patient for at least 2 hours. If repeated treatment is needed admission is indicated.

Decadron

Decadron is a steroid given to decrease inflammation, in this case for airway edema. The dose for children for croup, a similar situation, is:

  • Moderate to severe croup: 0.6 mg/kg IM/IV/PO
  • Mild croup: Consider 0.15 mg/kg PO, However 0.6 mg/kg dose is most effective
  • Maximum dosage in children: 10 mg

Improvement onset is usually within 6 hours . As onset takes a long time it’s important to administer early in treatment. Don’t expect decadron to provide immediate relief. Improvement continues at least 12-24 hours and may last 60-72 hours. The literature reports that it decreases the need for intubation by 80%.

Back to The Case

The team decided to keep the child in the emergency department overnight under close observation. She received periodic repeated treatments with racemic epinephrine when her stridor worsened again. They elected to risk not placing an IV, as this would cause the child to struggle and cry, perhaps precipitating airway obstruction from increasing the edema. They reasoned that if she decompensated, placement of an IV would be easy. This may or may not have been the case and was a calculated risk.

They had an OR on alert set up with a tracheostomy tray available in case the child decompensated and required intubation. They planned to transport the child at the first sign that things were getting worse and have a low threshold for making this decision to allow time for safe transport.

By morning, the stridor had resolved and the child did well.

What If Your Patient Decompensates?

As previously mentioned, the safest place to manage the airway of a decompensating child is the operating room. A child will not cooperative with an awake intubation. In the OR, a slow, careful induction with inhalation agent can be done in a controlled setting.

However, if in your judgement the patient is in danger of immediate death, and you can’t wait for more specialized help, proceed with caution. Call for the tools to do cricothyroidotomy or tracheostomy just in case you need them.

Make sure you have the equipment you need to use after you secure an invasive airway.  For example, if your choice is to do percutaneous cricothyrotomy with a large bore angiocath, you must be able to attach oxygen and ventilate through the angiocath. Make sure you have the jet ventilator hooked up and ready to go.

In the absence of a jet, have the correct adapters to hook up to an Ambu bag set up and ready to go. Don’t wait until you have a catheter in the cricothyroid membrane before you ask for something to attach it to. A previous article discussed use of percutaneous jet ventilation.

If a jet ventilator is unavailable, then there are several ways to connect the catheter to your ventilation system. The connector from a number 3 endotracheal tube fits snugly into the hub of any intravenous catheter. However, this tiny assembly is often difficult to hold while squeezing the bag. I prefer to place the connector from a number 7.5 endotracheal tube into the barrel of a 3 ml syringe.

Illustration showing the use of a 3 ml syringe and 7.5 ml adapter for an emergency percutaneous cricothyrotomy adapter to ventilate with an Bambu bag.

Emergency needle cricothyroidotomy and a simple, though less optimal, means of connecting it to a ventilation system when a jet ventilator is not available. This is a temporary ememrgency measure only as hypercarbia will occur.

The barrel of the syringe now mates to the hub of your catheter and gives you something more substantial to hold. You can also place an endotracheal tube within the barrel of a ten ml syringe and inflates the cuff to maintain the connection. You must ventilate vigorously to pass enough oxygen through the catheter.

Gas will escape through the mouth. You must allow the gas to escape and the patient to exhale, otherwise pneumothorax is a risk.

You can also attach the barrel from a tuberculin syringe to the catheter hub and connect this to oxygen tubing. If the oxygen tubing can then be connected to the fresh gas outflow from an anesthesia machine a “jet” can be jury rigged. Again, you must let the patient fully exhale after each breath.

Reports indicate that patients can maintain themselves for several minutes breathing spontaneously through a 10 g catheter. Although hypoxia is avoided hypercarbia will develop. However, any oxygen supplied during emergency treatment of airway obstruction is useful and buys time for more definitive airway management.

Never paralyze or sedate a patient with airway obstruction unless in your judgment paralysis is the only way to proceed safely. The muscle tone of the larynx may be the only factor maintaining the airway. The use of sedatives and muscle relaxants carries very high risk in the patient with fixed airway obstruction. If used they must be titrated extremely slowly and to effect. Use of agents that can be reversed, such as narcotics or midazolam , can be prudent.

Managing severe airway obstruction requires careful planning to make sure that at each step patient safety is optimized. While intubation should always be in your decision tree, in intubation is not your only option. Sometimes avoiding intubation is your safest choice.

May The Force Be With You

Christine Whitten MD
Author of  Anyone Can Intubate  5th Edition

 

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