Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading

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. Continue reading

Avoiding Difficult Intubation Of The Easy Airway

It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. We’ve all done it. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate). Continue reading

Intubating An Infant or Toddler

This article discussion some of the key anatomy, physiology, and technical points to intubating an infant or small child safely. I’ve been hard at work on writing and illustrating my upcoming book on pediatric airway management so I thought I would spend some time talking about care of our littlest patients.

Providers who infrequently care for children less than two years of age are often rightfully anxious when faced with a sick child, especially if airway management is required. This is especially true if the child is less than one. Healthy respect is certainly indicated because airway complications are one of the leading causes of pediatric cardiac arrest.

Children are not small adults. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously morphing until finally reaching the adult form and function. We all know this instinctively. When we look at a child we can often tell how old he or she is simply by looking at head size, characteristics of the face, length of neck, shape of the body, and how long the arms and legs are related to the trunk. It should not be surprising that the inside of the child is changing as well.

Photo placing oral airway in preparation to mask ventilating an infant

Even placing an oral airway and using a mask in an infant can seem more challenging because of the size and fragility of the patient.

Infants and young children are small. The head of a newborn infant can fit on the palm of my hand. The palm of a premature infant’s hand may be the same size as my thumbnail. It’s challenging to open the airway of such a small infant when adult fingers dwarf the size of the baby’s mouth and all of the instruments are smaller. And babies are fragile, with little reserve.

Like adults, children can be small or tall, lean or overweight. But unlike adults, their airway anatomy is changing shape and structural relationships as they grow. A particular 2 year old may be as tall as a particular 6 year old, or as heavy as a particular 8 year old, but all have very different airways.

Intubating an infant or small child is more of a challenge than an older child or adult both because of their anatomical differences as well as their physiologic predisposition for hypoxia. One can certainly argue that faced with elective care, that only experienced providers should manage the airways of infants and children less than two. However, medical care is not always elective.

Faced with a sick child, especially in more urgent settings, anyone who can ventilate and intubate an adult can also ventilate or intubate an infant or toddler safely —if they take the differences in anatomy and physiology into account, and are gentle and methodical in their approach. Illustrations and photos from Anyone Can Intubate: a Step by Step Guide, and Pediatric Airway Management: a Step by Step Guide. Continue reading

Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation

Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations.

Illustration of An alternate means of ventilation — insert an endotracheal tube connector into a nasal airway as in a. Place the nasal airway, close the opposite nostril and mouth. Ventilate as in b.

An alternate means of ventilation — insert an endotracheal tube connector into a nasal airway as in a. Place the nasal airway, close the opposite nostril and mouth. Ventilate as in b.

The Case

Many years ago I was taking care of a 40 y.o. man had Ludwig’s Angina, a serious, potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, often occurring in an adult with a dental infection. Continue reading

Risks of Placing Your Endotracheal Cuff Too High

When intubating, we all know to check the depth of the endotracheal tube (ETT). Most people believe this is just to ensure that the tube is not too deep and therefore causing a mainstem intubaton: intubating just one bronchus and therefore only one lung. However, there are significant risks with having the tube too shallow, placing the endotracheal cuff too high, and above the cords.

Endotracheal Tube Cuff Above The Cords

Illustration of endotracheal tube cuff too high and above the cords. Risk of accidental extubation is high when the cuff is above the cords.

Risk of accidental extubation is high when the cuff is above the cords.

In addition to ensuring that the tube is not too deep, also make sure that the cuff is not too high, and that it’s below the cricoid ring. Having the cuff above the cords happened to me just the other day and even I was fooled for a few minutes into thinking that I had a cuff leak. Continue reading

Should I Use A Cuffed or Uncuffed Endotracheal Tube In a Child?

When intubating children, the question always arises whether to use a cuffed or an uncuffed endotracheal tube (ETT). Historically uncuffed endotracheal tubes have been used when the child is less than about 8 years old. Why is it that we can get away with using an uncuffed tube in a young child, but not an adult? Are there advantages and disadvantages to each?  The answers comes from understanding some of the anatomical differences between children and adults. Continue reading