Introduction
Airway management is an essential part of pediatric resuscitation for many medical conditions. Prehospital pediatric airway management is a controversial entity. Advanced airway procedures are rare among children. In urban areas, intubation can be done on a child once every four to five years compared to adults. In conditions such as traumatic brain injury, cardiac arrest, and other medical emergencies, appropriate airway management, either via essential (bag-valve-mask ventilation) or advanced (endotracheal intubation), is essential to successful resuscitation. Endotracheal intubation has always been a choice for emergency airway management in adults or kids in both the hospital and prehospital settings. However, it has been suggested that the benefit of prehospital pediatric intubation is doubtful because of the increased rate of complication compared to intubation in the hospital. Various studies have assessed the benefit of prehospital pediatric airway management.
What Is Pediatric Airway Management?
Airway management is a set of techniques and procedures to prevent and relieve airway obstruction. This leads to an open pathway for a smooth gaseous exchange between the lungs and the atmosphere. Securing an airway is a crucial task for an anesthesiologist. As compared to adults, kids have significant anatomical and physiological differences, which impact the anesthesiologist's techniques for safe and effective airway control. Children have certain typical pathological processes, leading to anatomical or functional difficulties in airway management. The presence of even one of these conditions can lead to a difficult airway. Many instruments and devices have been designed to help airway management for such situations. Some of these have been adapted from adult designs but, in many cases, require alterations in technique to account for the anatomical and physiological differences of the pediatric patient.
How Is Prehospital Pediatric Airway Managed?
Endotracheal intubation is one of the frequently used prehospital pediatric airway management methods. However, it has been identified as having a high risk for safety events. Bag-mask ventilation, identification of appropriate-sized equipment, assessment of respiratory distress, tracheostomy care, and scene management are other ways of prehospital airway management that are likely to contribute to safety events. These types of airway management techniques, a lack of experience, and training in pediatric airway management and respiratory assessment are the root cause of possible errors.
The following are recommended while using in pediatric airway management:
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The correct size of pediatric equipment for newborns to adolescents should be available. All pediatric equipment should be routinely checked.
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The clinicians should be trained and equipped with age-appropriate pulse oximetry capnography equipment to help in the management of pediatric respiratory distress and airway emergencies.
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The clinicians should emphasize the use of noninvasive positive pressure ventilation and effective bag-valve-mask ventilation in children.
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Supraglottic airways can be used to manage the airway for pediatric respiratory failure and cardiac arrest.
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Advanced approaches to pediatric endotracheal intubation, including drug-assisted airway management, oxygenation, and use of direct and video laryngoscopy, should be used after proper research.
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Paramedic use of direct laryngoscopy to remove any foreign body in the pediatric patient should be carried out even when pediatric endotracheal intubation is not approved.
What Are the Different Types of Pediatric Equipment and Techniques Used in Airway Management?
The anatomic and physiologic differences between pediatric patients and adults demand specialized and dedicated pediatric equipment.
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Pulse Oximetry
Pulse oximetry is essential in the evaluation of respiratory distress both in children and adult patients. However, when an adult-sized probe is used on a child, it can yield inaccurate results, thus increasing decision errors in diagnosing and managing respiratory distress and failure.
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Capnography and Capnometry
These procedures are used to measure and record carbon dioxide in the respiratory system. These are useful for identifying patients with respiratory failure in children with moderate-to-severe respiratory distress.
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Supplemental Oxygen
Supplemental oxygen is used only in infants and young kids who may not tolerate other interventions and require only slight oxygen concentration increases compared to room air. It cannot be used in older children. The choice of oxygen delivery via nasal tubes or facemasks should be based on the severity of the illness, pulse oximetry measurement, and the patient's mental status for easy administration.
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Use of Noninvasive Positive Pressure Ventilation (NiPPV) In Prehospital:
Noninvasive methods of ventilation using a wide range of interventions commonly available in ambulances, such as the use of bag valve masks to increase respirations, to a wider variety of options more widely seen in the hospitals, such as continuous positive airway pressure (CPAP), heated humidified high-flow nasal cannula (HFNC), and bi-phasic positive airway pressure (BiPAP). NiPPV is evolving in pediatric critical care, leading to a reduction in respiratory severity as well as reducing the need for endotracheal intubation to an extent for children with asthma, bronchiolitis, and other lower airway diseases. Children treated with high-flow nasal cannula as primary therapy did not require rescue intubation during transport. The application of continuous positive airway pressure during prehospital management of acute respiratory distress resulted in reduced intubation rates and ICU (intensive care unit) stay.
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Bag-valve-Mask Ventilation
Bag-valve mask ventilation is a device that is designed to provide manual ventilation. It is a challenge to carry out the procedure correctly. It is important to select the appropriate bag valve masks.
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Supraglottic Airway Devices (SGAs)
Supraglottic airway devices have been used as rescue devices in failed airway resuscitation both in and out of the hospital. They have also been found useful as primary devices to secure airways.
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Endotracheal Intubation (ETI)
Pediatric endotracheal intubation is a high-risk procedure. Difficulty in achieving precision over the use, a decline of skills over time, high complication rates, and ill performance are some of the important issues to consider while using endotracheal intubation in kids.
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Prehospital Drug-Assisted Airway Management
Evidence has been found that endotracheal intubation carried out with sedative and paralytic medications, known as rapid sequence intubation, has been associated with an increased success rate, decreased hospital length of stay, and favorable results in pediatric patients.
Conclusion
The noninvasive ventilation modes for children in the prehospital setting have gained popularity. Effective bag-valve-mask ventilation is considered the primary method of supporting ventilation in the pediatric population. Additionally, the use of supraglottic airway devices as primary airway devices in pediatric patients has also gained popularity. Pediatric prehospital endotracheal intubation is not found to show much benefit in the management of pediatric emergencies such as trauma or seizures. Pediatric endotracheal intubation should not be routinely performed. Noninvasive ventilation modes and optimization of big valve mask ventilation efficacy would guide future prehospital strategies.
