Dr. Tim Horeczko’s podcast and show notes on Supraglottic Airways from the Pediatric Playbook are outstanding (yes, outstanding). The podcast and post were released March 1, 2017.
The podcast is approximately 30 minutes long and the pictures in the show notes that you will review as you listen to the podcast are great (yes, great).
So just click the link and listen, view, and learn.
Some highlights :
[Pediatric] endotracheal intubation is not everything.
Think of the supraglottic airway as a brick in the house of airway management.
The foundation of the building should be bag-valve-mask ventilation.
If you can position the patient, clear the airway, and bag the patient you can do anything.
But there are times when it is not so easy [to bag the patient]; where you need backup.
Supraglottic airways are a fantastic rescue device.
Bag-valve-mask ventilation is a two person skill. You as the airway manager should make the two handed mask seal while your assistant squeezes the under your guidance.
You will say to your assistant in a calm measured voice: “Squeeze, relax, relax. Squeeze, relax, relax.”
If you say it at the right calm cadence you and your assistant will be bagging at about 20 breaths per minute. [Each event is one second so 20 breaths per minute]
Adults need less – about ten to twelve per minute.
And infants need more – for your littlest patients say: Squeeze, release. Squeeze release.
See the show notes for a picture of the towel roll under the scapulae and a picture of the two handed mask application with jaw thrust.
Use nasal trumpets if needed. By the way, they work great for spontaneously breathing patients as well. You size them from the nares to the tragus.
If you’re using a bag-valve-mask, use an oropharyngeal airway sized from the incisors to the angle of the jaw.
Remember, if you can bag and suction, you can do anything.
Proper bag-mask ventilation saves lives, not fancy advanced airway procedures.
Nine month old Emily is brought in by ambulance for difficulty breathing. She was discharged yesterday with the diagnosis of bronchiolitis. And she’s been increasingly short of breath today.On arrival her heart rate is 180, respiratory rate 60, oxygen saturation 84%.She is pale. She is limp and poorly responsive. Just transferring her over to the gurney, her heart rate drops to 80.
You can see her turning gray in front of you. Without hesitation you place a shoulder roll (meaning a towel under the scapulae). You choose a mask that fits: From the bridge of the nose to the left of the chin. And bring her face up into the mask [with a jaw thrust] as you deliver deliberate breaths, just enough for chest rise.
Initially you try to sync with her but she abruptly becomes apneic and allows you to bag her.
Squeeze, release, release. Squeeze, release, release. The phrase is tranquil. The room calms with your mantra.And you avoid bagging for Emily at your own pulse rate.
While you can ordinate the rest of the care you notice that intermittently she has some resistance to bagging.
You recheck her position, making sure that her head and neck are midline and think maybe that large tongue is getting in the way.
You place an oropharyngeal airway and things seem to get better.
Emily’s mother then rushes in panicked: “My baby my baby! Please don’t put another tube down her throat.” You look up to see a tearful, desperate woman.
She goes on “she was a premature baby and she’s been intubated three times. And the last one was a nightmare.” You ask when the last one was and she says two days ago!
It turns out that there is more to the history than was available initially.
You think, Emily is at risk for subglottic stenosis.And she probably has some airway edema from her last intubation.
You are still wondering why she was sent home so early but no time for that. You have to make a decision.Emily remains apneic with bagging.
The good news is that Emily’s heart rate has normalized [meaning you’re doing a good job with your oxygenation and ventilation].It is in the 140s now and her oxygenation is in the mid-90s with bagging.
So you could just go on to rapid sequence intubation, and there is nothing wrong with that. But, you already know that this is a difficult airway and you have already made some real progress in stabilizing her.
You have a moment now to ask yourself: why not go straight to supraglottic device?
Start at 9:53
