Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?

Abstract

SummaryCricothyrotomy or insertion of a transtracheal device is a life-saving maneuver that may be performed on an emergent or semi-elective basis as a means of bypassing an obstructed upper airway. A surgeon is trained to perform this life-saving procedure whereas most anesthesiologists are not facile with the scalpel. It is for this reason that many percutaneous devices have been developed for use by surgeons and nonsurgeons alike. Unfortunately, the majority of such devices are designed for use in adults and ⁄ or teenagers but are not appropriate for neonates and infants. The unique anatomy of the infant larynx, the small size of the cricothyroid membrane, and the technical difficulty of locating the correct anatomical structures make the use of most of these devices impractical if not outright dangerous in neonates and infants. This paper will review many (but not all) of the available devices, associated literature, pitfalls and dangers. It is emphasized that each clinician should become familiar with the advantages and disadvantages of these devices and obtain training with simulators or animal models. A strategy for management of the 'cannot ventilate, cannot oxygenate, cannot intubate' situation should be developed with age and size appropriate equipment.

Unanticipated Difficult Airway in a Neonate: Are we Prepared for this CHAOS?

“…There are devices for low pressure oxygenation, such as Enk Oxygen Flow Modulator, Ventrain and Rapid O 2 . However, there are no published reports regarding the use of these devices in neonates and infants (5). A definitive tracheostomy should be performed, or else, dangerous plasma CO 2 levels may build up.…”

“…Hence, it is recommended to not perform a scalpel cricothyroidotomy in children aged <5 years. Cote et al (5) described that a transtracheal puncture with the head in extension and soft tissues pulled up and away as much as possible is a far safer procedure. A Teflon-made ventilation catheter (Ravussin), which is kink resistant and has a lateral flange for fixation, can replace the IV cannula.…”

Postępowanie w niespodziewanych trudnych drogach oddechowych u dzieci — stanowisko Sekcji Anestezjologii i Intensywnej Terapii Dziecięcej, Sekcji Przyrządowego Udrażniania Dróg Oddechowych Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii oraz Po

“…In older children dedicated sets are used, while in an emergency substitute instruments, such as intravenous cannulae, may be utilized [105][106][107]. In life-threatening situations when bag-mask ventilation and ventilation through Laryngeal Mask Airway (LMA) is not possible, the option to achieve the quickest possible oxygenation of the patient should be chosen, according to the available equipment and the physician's experience.…”

"Cannot ventilate cannot Intubate" Newborns

“…There is very little data on failed intubation in newborns and infants [2]. Surgical cricothyroidotomy is not recommended in pediatric patients due to the small size of the cricothyroid membrane [3].…”

“…Although surgical cricothyroidotomy is an option, it is a difficult procedure to perform in young children, infants and newborns. Transtracheal or transcricothyroid needle approach may be the only option for young children, infants and newborns that cannot be intubated and ventilated [2].…”