You can't arrive unprepared when it comes to working with an extraglottic airway device in a child. Not only do you need a Plan B, but Plans C and D also are essential.
Though extraglottic airway devices are not used routinely outside of pediatric anesthesia, children may arrive from the field with these devices in place. These devices also may be used as backups if standard airway intubation fails to support ventilation and oxygenation. Though challenging to stabilize in neonates who have difficult airways, the devices can be used in children weighing as few as 5 kilograms to support oxygenation and ventilation, although not all prehospital providers or hospitals stock sizes this small.
An important starting point in the discussion of pediatric alternative airway devices is to acknowledge that pediatric airways are just simply not easy. According to an article published in the January to March 2014 issue of the International Journal of Critical Illness and Anatomy Science, significant differences in anatomy, physiology and pathology exist between adults and children that influence airway management and its complexity. Though teens may be cared for using an adult algorithm, working with the airway in a 5- or 10-year-old is a different matter. The younger the patient, the more challenging is the airway management.
Extraglottic airway devices serve as backups or temporary devices to support oxygenation and ventilation. They are not intended for longer term use because they are not secure and do not protect lungs from aspiration; they will need to be changed to a definitive airway intubation. The device also needs to be appropriately sized for a child and utilized only when necessary.
"You don't need to put an extraglottic airway device in a patient who is breathing normally," says Dawit T. Haile, M.D., division chair of pediatric anesthesia at Mayo Clinic's campus in Rochester, Minnesota, who also has hospital privileges at Mayo Clinic Health System in Mankato, Minnesota. "They are only placed when patients can't oxygenate and ventilate with their own airways."
If a prehospital provider places an extraglottic airway device in a child and that patient arrives at your hospital, don't pull out the device. A plan is needed prior to removal and exchange, very often involving patient transfer, including the following:
It's critical that one or more providers with expertise in airway management are present to attend to the pediatric patient and intubate when an extraglottic device is taken out, intervening if alternate measures are required. The need for a specialist such as a pediatric ENT or pediatric anesthesiologist is a key distinction between caring for adults and children with these devices, as backup procedures are especially complicated and specific in a child.
Before removing the device, pause and vocalize to the rest of the medical team the contingency plans in case initial exchange measures fail. Possibilities for exchanging an extraglottic airway device include using a bronchoscope or an exchange catheter. Tracheotomy surgical equipment must be available, as well as pertinent staff members, who need to be part of the discussion.
Transfer and careful transport
As an extraglottic airway exchange requires considerable specialization, transfer to a higher level of care with appropriate staff is almost always needed for pediatric patients arriving with extraglottic airway devices. Once you've established that the device is working properly, speak to personnel at the receiving hospital to collaborate on any steps needed to keep the patient stable while at your facility and during transit.
Transporting a child with an extraglottic airway device in place is somewhat risky due to the potential of dislodgement, as it's difficult to maintain device seating in a child. In fact, in order to ensure that the device remains in place, emergency personnel may need to be positioned at the head of the child to hold the device the entire trip.
"With kids and extraglottic airway devices, you want to prepare for the worst scenario and have the health care providers involved who can deal with that worst-case scenario," says Dr. Haile.
For more information
Harless J, et al. Pediatric airway management. International Journal of Critical Illness and Injury Science. 2014;4:65.