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Thoughts From A Clinician

Thoughts from a Clinician

Airway management is a skill which many prehospital practitioners pride themselves.  Hours of practice, preparation, and lab time go into managing the airway.  One aspect of airway management that is focused on less often is the pediatric airway.  It is talked about and yes, maybe even practiced on, but what about the actual patient contacts?  Is that component present?  The pediatric airway can be characterized as a “high intensity, low volume” skill – and should require more practice than its counterpart – the adult airway, but yet, very rarely is that the case.

Managing the pediatric airway is very similar, in terms of procedure, to the adult airway, but there are also so many intricacies that make it oddly unique.  There are the anatomical and pharmacological differences to consider, not to mention the human factors component as well.  As prehospital practitioners, it is up to us to be the subject matter experts of all things airway – including pediatrics. With the pediatric population, it is important to remember that the set up for managing a pediatric airway will follow the same course as adults.  Even though pediatrics are unique, we cannot forget the systematic approach to airway management.  Consider that the presentation may change your approach, but the overall goal remains the same.  Place the appropriate sized endotracheal tube into the trachea and breathe for your patient.  Sounds simple enough, right? 

The first thing that guides our decision making process is patient presentation. 

What are the reasons to consider intubation?  Also, can the patient be managed with noninvasive ventilation techniques or do they require invasive action?  Next, what tools and pharmacological agents are appropriate for this patient?  Patient history and a competent physical exam will help to answer that question.  If there is a thorough history gathered, then we have more knowledge about the patient and how to effectively manage the airway.  The last part will be the most important step in the process - the execution of placing the breathing tube.  This includes the primary plan as well as two backup devices.  If we fail to plan, we can plan to fail.  This is where rehearsal of these scenarios will help manage human factors, stress, and effectively manage the pediatric airway. 

The next part of this procedure is to decide the pharmacological agents to be utilized.  Discussion, rehearsal, and local protocols will help guide us in the decision on medications are best used in this case.  Again, presentation will also guide us in the selection of the agents to use for sedation, paralysis, and post intubation care.  It is important to remember that part of this is knowing your pharmacology.  Reviewing the pharmacology agents carried and utilized at your service is vital to successful patient care. 

It cannot be overstated how important patient positioning is for this patient population.  Often the sniffing position gets over exaggerated and we end up making things harder for ourselves in direct laryngoscopy.  Small towel rolls under the shoulders will give you just enough for a good view.  In adult populations, the technique of “ramping” a patient is commonly used, however in th pediatric population - not so much.  This is one example of the subtle differences in the pediatric intubation versus the adult.  The days of intubating any patient in a supine position or flat, are gone.  Remember to set yourself (and your patient) up for success.

Of additional importance is to choose appropriate tube size, depth, and back up devices.  One of the biggest issues with pediatric airway management is improper tube size.  Most practitioners choose a smaller than needed tube size.  This hinders the provider’s ability to deliver adequate tidal volumes and pressures to the patient.  Other considerations are the type of tube.  Whether using cuffed or uncuffed, remember there is a significant difference between the two.  There is a one half to full size difference between cuffed and non-cuffed tubes.  To determine size of endotracheal tube, use the tools available.  Helpful item such as color based tape systems or other available devices can assist with this.  Another way to determine the ETT size for children <1 year old is this mathematical equation; age in years+16/4 (1).  This formula gives you the uncuffed tube size.  To get the cuffed size, simply subtract 0.5 (2).  Use whatever your protocols, guidelines, and procedures are for this situation.

Finally, choose the backup devices.  It is always my plan to get the tube on the first pass, however, there always needs to be a backup in place.  Many services will utilize King LT, LMA, or iGel.  No matter what you have at your service, make certain you have the size that is needed and one full size above and below.  Surgical or needle cricothyroidotomy should be considered in these scenarios as well.  Age and guidelines will play a role in which will be available to utilize.  Be sure that you practice both so you are familiar with the use of both interventions.  Always have suction readily available before attempting laryngoscopy.  Pediatric patients will likely have a lot of secretions or blood in the airway, so prepare to mitigate that situation.  All of these things should be set up prior to attempting intubation.  Remember plan for success and most likely you will find success. 

These things are brought up simply to make us better clinicians.  If we don’t think about our approach and practice the scenario we will never improve our practice.  These simple steps are considerations for all clinicians who care for pediatric patients, no matter how infrequent.  We challenge you to practice your pediatric intubation scenarios often and with different devices.  Part of the job that is both stressful and fun is that we often have no idea what we will face on a shift by shift basis.  Whether you are a twenty year veteran or new to HEMS it is important to prepare for the most unlikely scenario.  We hope that you will attend FlightBridgeED’s first symposium March 20-21, 2018 in Nashville, TN.  Thanks for reading and remember always think like a clinician.





Klint is a Flight Paramedic in Nebraska, USA.  He is a critical care educator for Distance CME, LLC, blog writer for FlightBridgeED, and is very active in FOAMed.  You can follow Klint on Twitter @NoDesat.    Klint W. Kloepping, FP-C, NRP, C-NPT, AAS, FlightBridgeED, LLC, This email address is being protected from spambots. You need JavaScript enabled to view it.


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