Great topic! I was hoping to hear more about sedation and paralytics for pediatric intubations. We get a lot of RSV and our kids needing intubation are frequently hypoxic before we start. This has led to docs not wanting to give meds out of fear of losing respiratory drive if the intubation is not successful. We sometime get only 10-20 seconds before the sats really tank. However, the success seems much higher with sedation and paralytics, just as in adults. How do you decide? Also, I listened with amusement as one of the narrators discussed twisting the tube to try and get it through the glottic opening. That is so frustrating to do while the seconds tick away. I like the new stiffer stylets made by glidescope -will go in a tube as small as 3.0. I have heard anesthesia has different stylets that work even better so we are trying to get a pediatric airway conference/training put together. Will have to have someone bring a Phillips 1. One last thing. If the kids are super congested and frothing due to RSV, some atropine via nebulizer or IV is worth a try if you have time to try and dry it up some. Interested in your thoughts. Again thanks.
For your question about paralytics--as long as I can BVM ventilate a patient, I definitely use paralytics with pediatric intubations to optimize my chance for success. Most children can be BVM ventilated fairly easily (especially with an oral airway and a two hand BVM grip). Once I decide to intubate, I usually BVM ventilate the child between pushing the paralytic and inserting the laryngoscope. If I am worried about aspiration, I have a low threshold for inserting an NG or OG tube prior to the intubation attempt. The other reason to use paralytics are laryngospasm--these are scary complications when intubating a pediatric patient who is not paralyzed.
As for the question about passing the tube through the glottic opening--if you are using a GlideScope, you need a stylet that has the shape of the GlideScope blade. You can shape the stylet yourself but now they do make pediatric GlideScope stylets as well. You do need to make sure that the stylet goes through the entire length of the tube until just about the end--if there is a floppy piece of tube sticking out far beyond the stylet then it is difficult to control the tube itself. It is easy for a pedaitric stylet to be pushed backwards a couple of cm during your intubation attempt so if I am having trouble controlling my tube I check to make sure the stylet is just about all the way to the end of the tube.
Whether I am using VL or DL, once the tip of the tube is touching the glottic opening but cannot pass through it, then I remove the stylet and twist the tube clockwise (sort of like holding a screwdriver) while advancing the tube forward into the airway. Often the triangular tip of the tube snags on the vocal cords and this maneuver can help the tip pass through the glottic opening after which the tube should advance easily (assuming that it is not too large of a tube). This is probably the most common reason I am asked to help out with a failed airway and by removing the stylet, twisting the tube while advancing it forward, and then downsizing the tube I am usually able to pass the tube successfully. I've actually stopped using a stylet altogether with DL for young children since it is so common to have difficulty passing the tube beyond the glottic opening and by using those three steps (no stylet, twisting, downsizing) I am able to pass the tube once I get a good view.
Hope this helps, Zak
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Thomas E., M.D. - March 6, 2020 7:52 PM
Great topic! I was hoping to hear more about sedation and paralytics for pediatric intubations. We get a lot of RSV and our kids needing intubation are frequently hypoxic before we start. This has led to docs not wanting to give meds out of fear of losing respiratory drive if the intubation is not successful. We sometime get only 10-20 seconds before the sats really tank. However, the success seems much higher with sedation and paralytics, just as in adults. How do you decide?
Also, I listened with amusement as one of the narrators discussed twisting the tube to try and get it through the glottic opening. That is so frustrating to do while the seconds tick away. I like the new stiffer stylets made by glidescope -will go in a tube as small as 3.0. I have heard anesthesia has different stylets that work even better so we are trying to get a pediatric airway conference/training put together. Will have to have someone bring a Phillips 1.
One last thing. If the kids are super congested and frothing due to RSV, some atropine via nebulizer or IV is worth a try if you have time to try and dry it up some.
Interested in your thoughts. Again thanks.
Tom Eglin
Zachary D. - May 1, 2020 3:16 AM
Hi Tom,
Thanks for your comments.
For your question about paralytics--as long as I can BVM ventilate a patient, I definitely use paralytics with pediatric intubations to optimize my chance for success. Most children can be BVM ventilated fairly easily (especially with an oral airway and a two hand BVM grip). Once I decide to intubate, I usually BVM ventilate the child between pushing the paralytic and inserting the laryngoscope. If I am worried about aspiration, I have a low threshold for inserting an NG or OG tube prior to the intubation attempt. The other reason to use paralytics are laryngospasm--these are scary complications
when intubating a pediatric patient who is not paralyzed.
As for the question about passing the tube through the glottic opening--if you are using a GlideScope, you need a stylet that has the shape of the GlideScope blade. You can shape the stylet yourself but now they do make pediatric GlideScope stylets as well. You do need to make sure that the stylet goes through the entire length of the tube until just about the end--if there is a floppy piece of tube sticking out far beyond the stylet then it is difficult to control the tube itself. It is easy for a pedaitric stylet to be pushed backwards a couple of cm during your intubation attempt so if I am having trouble controlling my tube I check to make sure the stylet is just about all the way to the end of the tube.
Whether I am using VL or DL, once the tip of the tube is touching the glottic opening but cannot pass through it, then I remove the stylet and twist the tube clockwise (sort of like holding a screwdriver) while advancing the tube forward into the airway. Often the triangular tip of the tube snags on the vocal cords and this maneuver can help the tip pass through the glottic opening after which the tube should advance easily (assuming that it is not too large of a tube). This is probably the most common reason I am asked to help out with a failed airway and by removing the stylet, twisting the tube while advancing it forward, and then downsizing the tube I am usually able to pass the tube successfully. I've actually stopped using a stylet altogether with DL for young children since it is so common to have difficulty passing the tube beyond the glottic opening and by using those three steps (no stylet, twisting, downsizing) I am able to pass the tube once I get a good view.
Hope this helps,
Zak