Video, Oxygen, Paralysis, and LMAs: Airway Management Highlights from the SPA Annual Meeting
Myron Yaster MD, Melissa Brooks Peterson MD, and Justin L. Lockman MD MSEd
The overall theme of the Annual meeting of the Society for Pediatric Anesthesia held in San Francisco was dealing with change and challenging the status quo. There were several lectures at the meeting that dealt with pediatric airway management issues, including:
1. Preventing Undetected Esophageal Intubation (UEI) by Sumit Das, MBBS, BSc, FRC
2. An Evidence Based Approach to the Neonatal Airway by Annery Garcia-Marcinkiewicz, MD
3. Comparison of Practices (US vs UK) by Simon Courtman, MBBS, FRCA and Kirk Lalwani, MBBS, FRCA, MCR (primarily a discussion of the perioperative management of tonsillectomy on both sides of the pond)
4. There's a Block for That! - Novel Analgesic Techniques for Pediatric Surgeries by Stephanie Pan, MD (A discussion of Suprazygomatic Maxillary Nerve Blocks for tonsillectomy)
Many of the lectures are still available on-line for registered attendees of the meeting and become available to all SPA members about 12 months after the meeting. Some are also available to all members in Featured Lectures on the SPA website. All of these lectures would be useful in your faculty conferences, journal clubs, and in building teaching portfolios for new faculty.
In today’s PAAD we will highlight the lecture by Dr. Annery Garcia-Marcinkiewicz, who reviewed airway management of pediatric patients with known or suspected difficult airways. She emphasized the advantages of indirect laryngoscopy devices – standard angle or hyperangular videolaryngoscopes (where available) – and associated techniques. She reminded us all of the need to provide supplemental oxygen during intubation in ALL patients. Much of the data presented in her lectures came from several publications from the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative (PeDI-C) and have been individually reviewed in previous PAADs.1-10
Perhaps the most important take home messages from Dr. Garcia-Marcinkiewicz’s lecture are: Begin with indirect techniques early, always provide supplemental oxygen during laryngoscopy, use muscle relaxants even if successful mask ventilation has not been established, and if intubation attempt(s) fail, place an LMA readily!
Let’s review some of these. “I don’t need no stinking video laryngoscope,” “I do just fine with a standard direct blade.” Unfortunately, the evidence does not support this, particularly in smaller and riskier airways, like in infants with craniofacial abnormalities. Indeed, the difficult airway collaborative has proved that starting with direct laryngoscopy and failing results in increasing complications after each failed attempt. The bottom line: the first attempt should be to use a videolaryngoscopy or a hybrid approach. Which type of video laryngoscope should you use? Hyperangulated blade? Or Non-hyperangulated blade? Is a tracheal tube passed over a fiberoptic scope better? While the “best” method is not clear and may depend on what you have available, Dr. Garcia-Marcinkiewicz did emphasize that if using a hyperangulated blade, a preformed stylet that matched the blade curve is essential for success, and advancing the camera and advancing the ETT should be done in tandem.
Providing supplemental oxygen during ALL intubations will minimize hypoxemia during apnea – especially with unanticipated difficulty intubating. This change of practice is not only for difficult intubations, it is for ALL intubations. Supplemental oxygen can be provided with simple nasal cannula, high flow nasal cannula, a nasopharyngeal airway attached to an endotracheal tube adaptor, or even a RAE tube placed in the oropharynx alongside of the cheek. All will provide passive oxygenation and prevent or minimize hypoxemia during apnea. We encourage you to include this in your practice even though we know that change can be hard!
There has been a long debate about the safety of using muscle relaxants during these procedures. Won’t it increase the risk of a lost airway? It turns out that the Pediatric Difficult Airway Collaborative has helped prove that there are fewer complications and increased success rate when paralysis is used!7 And most patients who are difficult to ventilate become easier with paralysis. Not to mention: sugammadex can reverse an intubating dose of rocuronium/vecuronium incredibly quickly and efficiently – so avoiding paralysis because of the fear of “burning bridges” just doesn’t make sense anymore. Another bubbameisa (old wives tale) goes down the drain!
It's easy for us to say that LMAs are important in the rescue pathway, and even easier for you to roll your eyes and say, “Of course!” But we’ve been doing this long enough to see that people don’t think clearly in emergencies; as I (JLL) always say, “Epinephrine is a neurotoxin!” (referring to its affect on us!). It’s shocking how often people forget this simple lifesaving maneuver when a blue apneic child is in front of them. We appreciate Dr. Garcia-Marcinkiewicz reminding the audience of this, and we would add another important step: calling for help early!
Finally, we note that there are many places in the US and around the world that don’t have access to all of the equipment and/or drugs we discuss in this (and other) PAADs. We don’t have easy answers to that conundrum except to say that it’s worth trying to obtain these things now that we know they’re safer. We also (as always) worry about the training implications of an entire future workforce that has never had to rely on direct laryngoscopy success (see the recent editorial Lancet Respiratory Medicine11) – but this worry does not change our opinion about the value of VL for our patients starting now. One simple solution to this is the method I (Melissa) use in the OR which was also mentioned at the meeting: When utilizing the CMAC high definition videolaryngoscope (IMHO the best of all the devices!), which has the advantage of a cadre of metal standard size and thickness blades, do first a DL by “covering the screen” literally or figuratively, and then utilize the screen during the same instrumentation sequence to utilize the benefits of the videoscope. So, you can have the benefit of both methods– and make sure you document both versions, so that the DL view is known from any type of intubation.
What are your thoughts? Send to Myron who will post in a Friday Reader response.
References
1. Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW: Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth 2023
2. Disma N, Fiadjoe J: Pediatric difficult extubation: The end of the movie matters! Paediatr Anaesth 2022; 32: 590-591
3. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A: 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136: 31-81
4. Peyton J, Park R, Staffa SJ, Sabato S, Templeton TW, Stein ML, Garcia-Marcinkiewicz AG, Kiss E, Fiadjoe JE, von Ungern-Sternberg B, Chiao F, Olomu P, Zurakowski D, Kovatsis PG: A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. Br J Anaesth 2021; 126: 331-339
5. Matava CT, Kovatsis PG, Summers JL, Castro P, Denning S, Yu J, Lockman JL, Von Ungern-Sternberg B, Sabato S, Lee LK, Ayad I, Mireles S, Lardner D, Whyte S, Szolnoki J, Jagannathan N, Thompson N, Stein ML, Dalesio N, Greenberg R, McCloskey J, Peyton J, Evans F, Haydar B, Reynolds P, Chiao F, Taicher B, Templeton T, Bhalla T, Raman VT, Garcia-Marcinkiewicz A, Gálvez J, Tan J, Rehman M, Crockett C, Olomu P, Szmuk P, Glover C, Matuszczak M, Galvez I, Hunyady A, Polaner D, Gooden C, Hsu G, Gumaney H, Pérez-Pradilla C, Kiss EE, Theroux MC, Lau J, Asaf S, Ingelmo P, Engelhardt T, Hervías M, Greenwood E, Javia L, Disma N, Yaster M, Fiadjoe JE: Pediatric Airway Management in COVID-19 patients - Consensus Guidelines from the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society. Anesth Analg 2020
6. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Jr., Fiadjoe JE: First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396: 1905-1913
7. Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, Patel V, Jagannathan N, Burjek N, Mensinger JL, Zhang B, Peeples KN, Kovatsis PG, Fiadjoe JE: A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesth Analg 2020; 131: 469-479
8. Fiadjoe J, Nishisaki A: Normal and difficult airways in children: "What's New"-Current evidence. Paediatr Anaesth 2020; 30: 257-263
9. Stein ML, Park RS, Kiss EE, Adams HD, Burjek NE, Peyton J, Szmuk P, Staffa SJ, Fiadjoe JE, Kovatsis PG, Olomu PN: Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry. Anaesthesia 2023; 78: 1093-1101
10. Garcia-Marcinkiewicz AG, Matava CT: Safe in the first attempt: teaching neonatal airway management. Curr Opin Anaesthesiol 2022; 35: 329-336
11. Senthil K, Daly Guris RJ, Vutskits L, Lockman JL: The law of unintended consequences: The crutch of video laryngoscopy. Lancet Respir Med 2023; 11(8): e75-6.