G456(P) Anticipation and management of the difficult paediatric airway in the emergency department: a series of cases encountered by a regional critical care transport service

Abstract

Centralisation of children’s services in the UK has decreased exposure of district general hospital (DGH) emergency department staff to paediatric airway management, especially in critically ill children. Regional Retrieval Teams such as the North West and North Wales Paediatric Transport Service (NWTS) provide advice and support but cannot be considered as the primary difficult airway management team leading to challenging scenarios, particularly for DGH teams managing patients with predicted or known difficult airways. Early recognition of the difficult airway is vital in decreasing morbidity and mortality, and anxiety for those involved. Prompt assembling of a competent multidisciplinary team in the emergency department, with appropriate equipment, drugs, monitoring as well as planning for failure or deterioration represents a major challenge.The difficult airway is the clinical situation in which a conventionally trained anaesthetist experiences difficulties with facemask ventilation, tracheal intubation, or both. Difficult intubation occurs approximately 0.42% in all elective paediatric tertiary intubations. Of these 0.08% occur in healthy children, increasing to 0.24% in the under ones. Difficult mask ventilation occurs in approximately 0.02%. Can’t intubate can’t ventilate situations occurs1 in 10–50,000 in adults. Paucity of published data on incidence of difficult airway during emergency intubation for respiratory failure is unknown, but likely to be significantly higher. NWTS data revealed 11.2% incidence of grade 2 or above laryngoscopy (357 intubations of critically sick 1–5 year olds); and in under 2 year olds 21% complication risk such as hypotension or hypoxia.We describe 8 cases referred to North West and North Wales Paediatric Transport Service (NWTS) from different emergency departments across the North West of the UK, that highlight importance of anticipating problems managing paediatric airways, and the proposed regional difficult airway and intubation guideline.The guideline highlights the importance of alternative plans required to ensure a successful outcome. Equipment and monitoring ideally should be standardised across all hospital departments where a critically sick child/neonate may present. Education and regular training in airway management reduces the risk of paediatric airway difficulties. Regional paediatric intensive care transport teams can facilitate access to specialist equipment and transfer to tertiary specialised units when required.