PICU Difficult Airway Cart

PICU Difficult Airway Cart

Difficult Airway Cart

Combination of

LMAs, lightwands, transtracheal jet ventilation set up, tube exchangers, emergent percutaneous tracheostomy set up, light source and 2.2 flexible bronochioscopes

Location - PICU Storage Room
Cost Center - Respiratory Therapy

Purpose of PICU Difficult Airway Cart

To maintain readily available pediatric airway equipment in order to quickly deal with an unexpected difficult pediatric airway.

Possible scenario uses:

Able to mask ventilate, requires eventual airway control but difficult to intubate.

Cannot mask ventilate/cannot intubate.

Reference:

Wheeler M. Management Strategies for the Difficult Pediatric Airway. Anesthesiology Clinics of North America 1998; 16 (4): 743 ? 7

Getting PICU Difficult Airway Cart to the Bedside

Physician

·  Request PICU Difficult Airway Cart.

Nursing/Respiratory Therapist

·  Bring Difficult Airway Cart immediately to bedside.

·  Unlock the Difficult Airway Cart using the appropriately labeled key kept in a box on a top shelf of the cart.

Difficult Airway Responsibilities

Respiratory Therapy

·  Maintain Difficult Airway Cart
Daily, 11 - 7 shift will check Difficult Airway Cart:
Make sure lock box on top of cart is locked and number matches
the last one recorded.
Make sure power plug is plugged in to keep batteries charged in equipment
Log both of these in log book
Monthly, 7 - 3 therapist will check inside contents of Difficult Airway Cart.
At same time a pharmacy staff member checks medications in cart.

·  Be acquainted with Difficult Airway Algorithm.

·  Know what is in the Difficult Airway Cart.

·  Be acquainted with the indications for the various components of the Difficult Airway Cart. Refer to the potential scenarios document.

·  Maintain patients airway, ventilation and oxygenation during attempts
to stabilize the airway.

·  Restock Difficult Airway Cart
Any equipment that is "cleanable" will be brought back to dirty utility room and processed appropriately.

Nursing

·  Bring Difficult Airway Cart immediately to bedside.

·  Unlock the Difficult Airway Cart using the appropriately labeled key kept in a box on a top shelf of the cart.

·  Be acquainted with Difficult Airway Algorithm.

·  Know what is in the Difficult Airway Cart.

·  Be acquainted with the indications for the various components of the Difficult Airway Cart.

·  Maintain IV access.

·  Monitor patient vital signs.

·  Deliver medications as needed.

·  Document circumstances surrounding the use of the Difficult Airway Cart on the Code Blue Sheet.

·  Return Difficult Airway Cart to original location.

Pharmacy

·  Maintain the medications on the Difficult Airway Cart.

·  Restock medications after use of the Difficult Airway Cart.

PICU Residents

·  Be acquainted with Difficult Airway Algorithm.

·  Know what is in the Difficult Airway Cart

·  Be acquainted with the indications for the various components of the Difficult Airway Cart

·  Assist Critical Care Physicians

Critical Care Physicians

·  Be acquainted with Difficult Airway Algorithm.

·  Know what is in the Difficult Airway Cart.

·  Be acquainted with the indications for the various components of the Difficult Airway Cart.

·  Assemble and use various components of the Difficult Airway Cart to provide an airway for the patient.

·  Consultation with anesthesiology, ENT, surgery as needed.

Difficult Airway Cart Contents

TOP SHELF

End tidal CO2 monitor
Daily log, copies of policy and reference material.

MIDDLE SHELF

Fiberoptic Light Source, Olympus, for Bronchoscope

Kangaroo Light Source for thin fiberoptic equipment

Keep battery charger plugged in until ready for use.
Must be disconnected from battery charger before use.

Store Intubation handles (keep in charger and plugged into power) (2)

TABLE TOP

Work area for bronchoscopy equipment

*One key in clear plastic box (*Locked with coded safety lock) :
1. Small key opens the cart.

2. Tray of starz laryngoscope blades, sizes 0-4 (straight & curved) (2)

DRAWER 1

Equipment for bronchoscope use:

1. Ovapassian Airway, Kendall Curity 6075, adult (1) and pediatric (1)
2. Swivel adapters, DHD Healthcare, DHD 66-1991 (2)
3. Fiberoptic Intubating Mask
Size 1 (1) 30-40-001
Size 3 (1) 30-50-333
Size 5 (1) 30-40-005
4. Topical lidocaine 2% (IV preparation)
20 mg/ml (for nose and pharynx)
10 ml ampule (1)
6. Topical lidocaine 1% (IV preparation)
10 mg/ml (for trachea and bronchi)
10 ml ampule (1)
7. Non-bacteriostatic 0.9% saline, preservative free
10 ml single dose vial (5)
8. Oxymetazoline HCL 0.05% Nasal Spray, 15 ml bottle (1)
9. Xylocaine 2% (Lidocaine) jelly, Uro-Jet 054-3013-00;
10 ml tube (1)
10. Water soluble sterile, bacteriostatic surgical lubricant .
5 g (3)
11. 5 ml syringes, luer slip tip (6)
12. 18 G needles (5)
13. Gauze pads 4x4, Kendall Curity Gauze Sponges 6939 (10 to a pack)
14. Puritan Cotton tip applicators (100-6 inch pack) (1)
15. Suction trap for collecting specimens (2)
16. Tape to label different medication syringes
Lidocaine (1 roll)
Blank medication lable tape for miscellaneous drugs
(1 roll)
Non-bacteriostatic saline
17. White Cloth Tape (1 roll)

DRAWER 2

1.  Thin non-flexible fiberoptic scope the eyepiece.

2.  Thin non-flexible fiberoptic scope without eyepiece.

3.  Magill forceps
- Pediatric
- Adult

4.  Disposable CO2 indicator; adult (1), Pediatric (1)

5.  Large hemostats (1)

DRAWER 3

1. Reusable Laryngeal Mask Airway
- Size 1.0 (1)
- Size 1.5 (1)
- Size 2 (1)
- Size 2.5 (1)
- Size 3 (1)
- Size 4 (1)
2. Syringe 5ml (1)
3. Syringe 10ml (2)
4. Syringe 20ml (1)
5. Syringe 60ml (1)
6. LMA chart with description of the use of different size laryngeal masks per weight.
7. Tracheal Lightwand

8. Halogen Headlight and power Cord (1)
- Handle (2)
- Adult Lightwand (2)
- Child Lightwand (2)
- Infant Lightwand (2)
- Extra AAA Batteries for Lightwand handle (3)

DRAWER 4

1. 2.2 Flexible Bronchoscope Olympus (1)

DRAWER 5

1. Anesthesia Associates Jet Ventilator for Transtracheal Jet Ventilation (1)
2. Accessories for Transtracheal Jet Ventilation:
- 14 G angiocath (2)
- 3.5 cc syringe (2)
- 10 cc syringe (2)
- Clean Adapter from a 3.5 endotracheal tube (2)
- Clean Adapter from a 7.5 endotracheal tube (2)
- 7.0 cuffed endotracheal tube (2)

3. Cook Airway Exchange Catheter with Rapi-fit adapters
- ID 2.3mm for endotracheal tube ID 4mm or larger (2)
- ID 3.0mm for endotracheal tube ID 7mm or larger (2)
4. Melker Emergency Cricothyrotomy Catheter Set (Cook Critical Care) (1)
3.5mm ID, 3.8cm C-TCCS-350
5. Cook Retrograde Intubation Set (Cook) (1)
C-Retro-11-0-70-38j-110

DRAWER 6

1. Paper disposable gowns
2. Masks
3. Gloves, non-sterile, non-latex
- Size Medium and Large
4. Saline 250 ml bottle for bronchoscopy use (3)

Potential Uses for Difficult Airway Cart Contents

Flexible, fiberoptic, intubating bronchoscope

Scenarios where potentially useful:

If anticipated difficult airway, should be first modality used

·  Cervical spine pathology

o  Trauma

o  Confirmed

o  Suspected

·  Limited motion

o  Klippel-Feil syndrome

o  Rheumatoid arthritis

o  Ankylosing spondylitis

o  Instability associated with specific conditions

o  Down syndrome

o  Larsen Syndrome

o  Mucopolysaccaridosis

o  Spondyloepiphyseal dysplasia

o  Metatrophic dwarfism

o  Kniest Syndrome

o  Chondrodysplasia puncta

o  Chondrodystophica calcificans congenita

·  Decreased cervical mobility

Combined techniques

·  Fiberoptic assisted intubation via LMA

·  Retrograde wire assisted intubation

·  Rigid laryngoscopy and flexible fiberoptic scope

Bullard Laryngoscope

Useful in clinical scenarios where:

·  Limited mouth opening

o  Requires less than 1 cm of mouth opening to insert

·  Suspected cervical spine injury

o  Minimal neck movement required to perform intubation

·  Maxillofacial trauma where mouth opening may be limited and visualization of potentially traumatized oropharynx and larynx is preferred

LMA

Pediatric Applications

·  Establishment and maintenance of a patent airway during general anesthesia with spontaneous or controlled ventilation

o  Easily inserted and positioned blindly

o  Even if LMA not ideally positioned, patent airway generally achieved

·  Provide access to blind passage of endotracheal tube into trachea

·  Provide a guide to laryngeal inlet for the fiberoptic bronchoscope

·  Awake tracheal intubation in recognized difficult airway

·  Emergency airway where one cannot ventilate or intubate

Advantages

·  Rapid establishment of an airway in pediatric patient without necessity for muscle relaxation

·  More suitable and trouble-free airway than the face mask

·  Does not have to be optimally placed for a suitable airway to be maintained

·  Larger size of airway tube reduces airway resistance

Disadvantages

·  Optimal air leak around LMA must be limited (average, 20-25 cm H20) to avoid insufflation of stomach. This restricts amount of positive pressure that can be applied to lungs.

·  Not useful in stenting or maintaining patency in tracheomalacia or a trachea that is compressed or is obstructed at or below the laryngeal inlet

·  May be difficult to differentiate between laryngospasm and bronchospasm

·  Larger size of airway tube may increase dead space and amount of rebreathing

Complications

·  Occlusion of glottis by distal tip of the cuff

·  Backfolding of epiglottis

·  Rotation of LMA along the axis due to misplacement or displacement

·  Abnormal airway tissue at or below the level of the glottis may also obstruct the airway

·  Inadequate levels of anesthesia may contribute to difficulty inserting resulting in repeated attempts and local trauma, laryngospasm

·  Gastric distention, regurgitation.; aspiration possible

·  Trauma to oral cavity, larynx, displacement of deciduous teeth

Lightwand

Useful in clinical scenarios where:

·  Limited mouth opening

·  Minimal to no mouth opening required to successfully intubate

·  Suspected cervical spine injury

·  Does not require neck flexion or extension

·  Secretions or blood causing poor laryngeal visualization

Disadvantages

·  Since blind procedure can cause pharyngeal trauma, arytenoid dislocation

·  Since blind procedure, contraindicated if anatomic abnormalities are present such as trauma, tumor, infection, foreign body

·  Lightwand-guided intubation can be difficult in patients who are morbidly obese; have short, thick necks; large tongue; long, floppy epiglottis.

Transtracheal jet ventilator

Indication

·  Emergency situations where a patients trachea cannot be intubated or ventilation by mask is not effective

Caution

·  Technique not advisable in infants and children under 5 years of age due to small and cephalad glottic and subglottic regions as well as narrow mobile tracheal airway in neonates and infants.

·  Increased incidence of subcutaneous emphysema, pneumothorax, vasovagal events pneumomediastinum, inadvertent placement into esophagus

Percutaneous cricoidthyroidotomy

Indication

·  Procedure of choice for emergency access of airway in all patients, regardless of age, when conventional means of airway control not possible.

Caution

·  Difficult to perform in very young child due to anatomical constraints

o  Close approximation of cricoid and thyroid cartilages

o  Lack of functional cricothyroid membrane in neonates, infants

o  Short neck

o  Trachea about size of a pencil

o  Trachea flaccid, mobile, difficult to locate

o  Funnel shaped larynx in infants narrowest at level of cricoid cartilage

Complications

·  Bleeding

·  Subcutaneous emphysema

·  Pneumothorax

·  Pneumomedistinum

·  Esophageal perforation

PEER Review

Code Blue Sheet Documenting the Use of the Difficult Airway Cart will trigger a PICU PEER Case Review of the events leading to the use of the cart and the events during the carts use.

Difficult Airway Mock Codes in the PICU

The objective of these mock codes will be:

·  Practice getting the equipment to the bedside

·  Using a scenario, describe how the various difficult airway adjuncts could be helpful in a situation where there is inability to both mask ventilate and intubate.

References for further readings/self study

1. Gregory GA, Riazi J. Classification and Assessment of the Difficult Pediatric Airway. Anesthesiology Clinics of North America 1998; 16 (4): 729 - 741
2. Wheeler M. Management Strategies for the Difficult Pediatric Airway. Anesthesiology Clinics of North America 1998; 16 (4): 743 -752
3. Gutstein HB. Use of the Bullard Laryngoscope and Lightwand in Pediatric Patients. Anesthesiology Clinics of North America 1998; 16 (4): 795- 813
4. Borland LM, Casselbrant M. The Bullard Laryngoscope A New Indirect Oral Laryngoscope (Pediatric Version). Anesth Alalg 1990; 70: 105- 108
5. Fisher QA, Tunkel DE. Lightwand Intubation of Infants and Children. Journal of Clinical Anesthesia 1997; 9: 275- 279
6. Riazi J, Morrison DE. The Laryngeal Mask Airway in Pediatric Anesthesia. Anesthesiology Clinics of North America 1998; 16(4): 813- 825
7. Brain AIJ. The Intavent Laryngeal Mask, Instruction Manual. Gensia Pharmaceuticals Inc, 1992
8. Auden SM. Flexible Fiberoptic Laryngoscopy in the Pediatric Patient. Anesthesiology Clinics of North America 1998; 16 (4): 763- 793
9. Soriano SG, Kim C, Jones DT. Surgical Airway, Rigid Bronchoscopy, and Transtracheal Jet Ventilation in the Pediatric Patient. Anesthesiology Clinics of North America 1998; 16 (4): 827- 839
10. Peak DA, Roy, S. Needle Cricothroidotomy Revisited. Pediatric Emergency Care 1999; 15(3): 224 - 226