Background

The paediatric airway is distinct from that of the adult. The epiglottis is floppy and the larynx is shorter, more anterior, and more cephalad. The larynx is narrower and therefore more prone to obstruction by oedema, scarring, fluids, or foreign bodies. The cartilage of the larynx is also softer, which makes palpation of landmarks on the skin more difficult. The cricoid ring is the only spot where cartilage encircles the paediatric trachea, and it is also the narrowest portion of the airway (Fig. 23.6.1).

Fig. 23.6.1 Locating the cricoid membrane. Comparison of adult (A) and paediatric (B) airways. Note funnel shape of paediatric airway with narrowest portion at cricoid ring.

The vast majority of paediatric airway emergencies can be readily managed with bag–valve–mask (BVM) ventilation and/or tracheal intubation (TI). Rarely, a child presents with complete airway obstruction or anatomic abnormalities, and ventilation with BVM or TI is impossible. In these situations, a surgical airway may be necessary to provide life-saving oxygenation and ventilation to avoid anoxic brain injury. Surgical airways in children include: needle cricothyroidotomy; surgical cricothyroidotomy; and, rarely, tracheostomy. Placing a needle, catheter or tube directly into the trachea through the neck will temporarily relieve airway obstruction or bypass anatomic abnormalities.

In children under the age of 5 years, the membrane between the thyroid cartilage and the cricoid cartilage, the cricothyroid membrane (see Fig. 23.6.1), is extremely small. For this group, needle cricothyroidotomy is easier than surgical cricothyroidotomy. While the needle technique will provide emergency oxygenation, it may not provide adequate ventilation, especially over time. Even a jet ‘ventilator’, a rescue device that attaches to the needle and provides intermittent bursts of high-pressure oxygen to simulate the normal respiratory cycle, may not allow for adequate ventilation and clearance of CO₂.

In children 5 years and over, surgical cricothyroidotomy is easier and more effective, because it creates a larger conduit and allows both immediate oxygenation and ventilation via a bag–valve device. Tracheotomy in a young child is extremely difficult to perform emergently and is rarely indicated in the emergency derpartment.

Indications

• Failure to ventilate with BVM and/or TI.

• Obstructed or disrupted larynx.

Table 23.6.1 lists situations in which these indications occur. The most common circumstances in which intubations fail are the presence of massive nasopharyngeal haemorrhage, large tongue haematoma, laryngeal spasm, laryngeal stenosis, or obstruction of the airway by a foreign body that cannot be removed.

Table 23.6.1 Situations requiring cricothyroidotomy
Trauma • Laryngeal fracture • Airway burns • Massive haemorrhage • Foreign body • Subglottic stenosis (late) • Burn contractures (late)
Congenital abnormalities • Laryngeal atresia/stenosis/clefts • Tracheoesophageal fistula • Pierre–Robin syndrome • Treacher–Collins syndrome
Cervical spine abnormalities • Trisomy 21 syndrome • Klippel–Feil malformation • Torticollis
Inflammatory/infectious • Severe croup • Epiglottis • Bacterial tracheitis • Retropharyngeal abscess • Cricoarytenoid arthritis
Laryngeal spasm

Contraindications

• Presence of a secure airway.

• Traumatic destruction of the cricothyroid membrane.

• Transection of the trachea with retraction of the distal segment.

• Surgical cricothyroidotomy is relatively contraindicated in children under the age of 5 years. In this group, perform needle cricothyroidotomy.

Needle cricothyroidotomy

Equipment

Table 23.6.2 lists the equipment for this procedure, which can be divided into three categories:

Oxygen source. A transtracheal jet ventilator device is ideal. It provides high-pressure 100% oxygen (50 psi) in intermittent bursts, which allows more time for passive CO₂ exhalation (Fig. 23.6.2). Alternatively, use a bag–valve device connected to 15 L min^–1 of wall oxygen.

Adaptors. The jet ventilator device connects directly to the catheter at the neck. To use the bag–valve system, attach a 3-mm paediatric tracheal tube adapter with one end connected to the bag–valve device and the other to the end of the cricothyroidotomy catheter. Alternatively, set up a ventilation system with a 3-mL syringe and an 8-mm tracheal tube that attaches to the bag–valve device (Fig. 23.6.3).

Needle/cannula. A 14G over-the-needle catheter.

Table 23.6.2 Equipment for needle cricothyroidotomy
Oxygen source • Jet ventilator (50 psi) Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Syncope Abdominal and pelvic trauma Paediatric advanced life support (PALS, APLS) Pertussis Infective endocarditis Availing web-based resources Stay updated, free articles. Join our Telegram channel Tags: Textbook of Paediatric Emergency Medicine Sep 7, 2016 \| Posted by admin in EMERGENCY MEDICINE \| Comments Off on The surgical airway Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access