Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Critical Care Medicine, Center for Simulation, Advanced Education, and Innovation at The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Paediatr Anaesth. 2020 Mar;30(3):257-263. doi: 10.1111/pan.13798. Epub 2020 Jan 14.
Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit.
Expert review of the recent literature.
Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation-associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration.
Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.
小儿困难气道是最具挑战性的临床情况之一。我们将回顾手术室、重症监护病房、急诊科和新生儿重症监护室中儿科正常和困难气道管理的新概念和证据。
对近期文献的专家综述。
认知因素、团队合作和沟通在管理小儿困难气道中起着重要作用。早期的研究以整体的方式评估了可视喉镜，其效果的结论并不明确。然而，可视喉镜之间存在实质性差异，特别是有角度和无角度的叶片具有不同的学习和使用特点。每种气道设备都有其优缺点，结合这些设备利用各自的优势可能会取得成功。在儿科重症监护病房、急诊科和新生儿重症监护室中，经常报告与气管插管相关的不良事件和低氧血症。特定的患者、临床医生和实践因素与这些事件相关。在手术室和其他临床区域，使用被动给氧会提供额外的喉镜检查时间。在困难气道患者中使用神经肌肉阻滞剂曾被认为是禁忌的。来自观察性研究的新证据表明，在手术室中，使用或不使用神经肌肉阻滞剂的控制性通气与较少的不良事件相关。同样，一项多中心新生儿重症监护室研究表明，接受神经肌肉阻滞剂的婴儿发生不良事件的情况较少。对于预计神经肌肉阻滞剂给药会加重气道塌陷的粘多糖贮积症、头颈部放疗、气道肿块和外部气道压迫的患者，应避免使用神经肌肉阻滞剂。
负责治疗小儿困难气道的临床医生应考虑新的认知模式和概念，利用多种设备的优势，并考虑在某些情况下替代麻醉方法，如控制性通气和使用神经肌肉阻滞剂。麻醉师可以与重症监护、急诊和新生儿科临床医生合作，以提高所有临床环境下气道管理的安全性。
