Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary.

Children are not miniature adults: in many ways normal pediatric anatomy and physiology make children more vulnerable to hypoxia, respiratory distress, and respiratory failure. Compared to adults, the leading cause of preventable death in pediatric emergencies – both medical and trauma – is failure to adequately manage the airway. Pediatric respiratory events carry a higher mortality than adult events (1).

I had my first introduction to just how different children are as a senior medical student on the anesthesia service — an elective that eventually proved life changing. My teacher had asked me what I wanted to do on the rotation and I had requested to take care of children. That resulted in a long pause in the conversation and a non-committal comment that we would just have see to how that went as the rotation progressed. Finally, on my last day my teacher assigned me to a room full of pediatric patients having either ear tube placement or tonsillectomies. Every child was a different age and every child seemed to have different anatomy. My teacher spent the day showing me how to adjust my newly acquired skills to each child. I left that rotation which deeper respect for the subtleties of pediatric airway management.

There is good reason why most providers are more nervous taking care of children, especially young children less than 2 years of age. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously changing. Managing the airway of a premature infant requires a slightly different technique than managing the airway of an older infant, a toddler, a child and a teenager. Not big differences, but enough to make care of the pediatric airway more challenging, especially for providers who care for children infrequently.

Fortunately, most children have easily managed airways. If you understand the differences, taking care of the typical pediatric airway is not difficult.

It’s a common trend to concentrate care of children in the hands of those who are more experienced. For example, anesthesia in young children is more frequently being done by pediatric anesthesiologists in children’s hospitals. While good in many ways, this trend deprives other providers of caring for children — making them less prepared for when they do have to care for a small child.

For those of you who rarely care for pediatric emergencies this book will teach you the anatomy, physiology and technical differences in recognizing respiratory distress, opening an airway, ventilating, and intubating infants and children. For those of you who routinely care for children, this book will share some of the tips and tricks I’ve learned for managing more challenging airways from 4 decades of practicing anesthesia.

Even if you don’t perform intubation yourself, chances are you will be assisting someone who does. Understanding how the techniques are performed will allow you to more effectively assist and improves the chance for a good outcome. Dosages, advantages and disadvantages of the different drugs for rapid sequence induction are also covered.

This book gives you step by step instructions on basic airway management guided by 267 illustrations and photos, plus over an hour of on-line video clips. These free video clips provide hours of footage of actual patients undergoing real surgical procedures, manikin demonstrations, and animations. The URL to my video page, which you’re welcome to use, is here.

The goal of Pediatric Airway Management is to give you a visual picture of airway management and intubation for each age of childhood. As you proceed through the book, use the video clips to picture yourself performing the steps. I hope my efforts make you confident in your ability to help children breathe. Anyone can learn how to to open an airway and ventilate a child.

My sincere wish is that this new book helps in the care of our littlest patients, no matter where they are.

May The Force Be With You!

Christine E. Whitten MD

 

 

 

 

 

 

Intubation During Cardiac Resuscitation

Intubating patients during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic technique of intubation. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading

In Airway Emergencies Always Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway: the dreaded “can’t intubate-can’t ventilate” scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading

Hair Style Can Impact Intubation

Healing Little Heroes director dressed as Darth Vader at Ronald McDonald House, San Diego

Our Healing Little HeroesFoundation  founder dressed as Darth Vader at Ronald McDonald House, San Diego

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Continue reading

A Flood of Blood in the Airway

During intubation,  any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading

Intubation With A Curved Blade

Direct laryngoscopy depends on being able to bring the 3 axes of the airway into alignment to see the larynx. Curved blades are commonly used, especially by beginners because they are more forgiving of less than optimal placement and provide more room to pass the tube. However, it’s important to use them correctly. This article will discuss intubation technique using a curved blade. Straight and curved blades use different techniques for bringing the larynx into view. For a discussion of how to use a straight blade click here. Continue reading