Pharyngeal Oxygen Insufflation During AirTraq Laryngoscopy Slows Arterial Desaturation in Infants and Small Children

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis

BACKGROUND

Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.

METHODS

This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.

RESULTS

After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.

CONCLUSION

This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.

CLINICAL TRIAL REGISTRATION

Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Sustained pharyngeal inflation in infant airway-Flexible bronchoscopy measurements

Sustained pharyngeal inflation (SPI) with pharyngeal oxygen flow and nasal closure (PhO2-NC) technique create positive inflation pressure in the airway. This study measured the peak inflation pressure (PIP) levels and image changes with SPI-assisted flexible bronchoscopy (SPI-FB) and compared the effects in the pharyngeal space and mid-tracheal lumen. This prospective study enrolled 20 participants aged 6 months to 3 years. Each participant underwent sequential SPI-FB of four different durations (0, 1s, 3s, and 5s) for three cycles. We used a 3.8 mm OD flexible bronchoscope to measure and analyze PIP levels, images, and lumen dimension scores. A total of 480 data were collected. The mean (SD) age and body weight were 12.0 (11.5) months and 7.8 (7.5) kg, respectively. The mean (IQR) PIPs were 4.2 (2.0), 18.5 (6.1), 30.6 (13.5), and 46.1 (25.0) cmH2O in the pharynx and 5.0 (1.6), 17.5 (6.5), 28.0 (12.3), 46.0 (28.5) cmH2O in the mid-trachea at SPI durations of 0, 1s, 3s, and 5s, respectively. The PIP levels had a positive correlation (p <0.001) with different SPI durations in both pharynx and trachea, and were nearly identical (p = 0.695, 0.787, and 0.725 at 1s, 3s, and 5s, respectively) at the same duration except the 0 s (p = 0.015). Lumen dimension scores also significantly increased with increasing SPI durations (p <0.05) in both locations. The identified lesions significantly increased as PIP levels increased (p <0.001). Conclusion: SPI-FB using PhO2-NC with durations up to 3s is safe and informative technique that provides controllable PIP, dilates airway lumens, and benefits lesion detection in the pharyngeal space and mid-tracheal lumen.

The efficacy of apneic oxygenation during intubation using a prototype of an oxygenation laryngoscope - a technical simulation

BACKGROUND

Recently, a non-commercial oxygenation laryngoscope was able to maintain apneic oxygenation during simulated intubation efforts. Since that prototype was 3 mm wider than a standard Macintosh laryngoscope blade, the intubation performance of this device may differ from standard blades. A new prototype of an oxygenation laryngoscope was developed, consisting of a standard-size Macintosh blade and a fixed oxygen supply line to the side. Actually, it is unclear at which point of this blade the oxygen supply line should end to facilitate the best possible oxygen supply for apneic oxygenation.

METHODS

In this simulation study using a standardized human airway manikin, the efficacy of apneic oxygenation by oxygen insufflation using standard and modified Macintosh blades was compared: a standard Macintosh blade without oxygen supply line as control, one with an additional oxygen supply line ending proximal near the handle, one with the line ending at the middle of the blade, and one with the line ending near the tip. A preoxygenated test lung was connected to an oximeter with a flow rate of 200ml/min, simulating oxygen consumption of a male adult, and to the trachea of an anatomically correctly shaped airway manikin. Apneic oxygenation was performed and oxygen content was measured over a 20-minutes observation period. Experiments were repeated five times for each laryngoscope blade.

RESULTS

Oxygen percentage in the test lung dropped from 100 ± 0% at the start of the experiment to 53 ± 1.5% in the room air control group (p < 0.001 compared to all other groups), and to 74 ± 2.5% in the proximal oxygen line group, whereas oxygen percentage remained at 100% in both the medium and distal oxygen line groups (p = 1 between these groups; p < 0.001 between all other groups).

CONCLUSIONS

In this simulation study with a preoxygenated airway manikin, the use of a modified Macintosh laryngoscope blade with oxygen line attached at the tip or at the middle were able to maintain apneic oxygenation without measurable drop of oxygen content over 20 min. Proximal placement of the oxygen supply line still showed an advantage against room air, however it did not completely prevent room air from entering the airway.

TRIAL REGISTRATION

Not applicable.

Providing Oxygen during Intubation in the NICU Trial (POINT): study protocol for a randomised controlled trial in the neonatal intensive care unit in the USA

INTRODUCTION

Nearly half of neonatal intubations are complicated by severe desaturation (≥20% decline in pulse oximetry saturation (SpO2)). Apnoeic oxygenation prevents or delays desaturation during intubation in adults and older children. Emerging data show mixed results for apnoeic oxygenation using high-flow nasal cannula (NC) during neonatal intubation. The study objective is to determine among infants ≥28 weeks' corrected gestational age (cGA) who undergo intubation in the neonatal intensive care unit (NICU) whether apnoeic oxygenation with a regular low-flow NC, compared with standard of care (no additional respiratory support), reduces the magnitude of SpO2 decline during intubation.

METHODS AND ANALYSIS

This is a multicentre, prospective, unblinded, pilot randomised controlled trial in infants ≥28 weeks' cGA who undergo premedicated (including paralytic) intubation in the NICU. The trial will recruit 120 infants, 10 in the run-in phase and 110 in the randomisation phase, at two tertiary care hospitals. Parental consent will be obtained for eligible patients prior to intubation. Patients will be randomised to 6 L NC 100% oxygen versus standard of care (no respiratory support) at time of intubation. The primary outcome is magnitude of oxygen desaturation during intubation. Secondary outcomes include additional efficacy, safety and feasibility outcomes. Ascertainment of the primary outcome is performed blinded to intervention arm. Intention-to-treat analyses will be conducted to compare outcomes between treatment arms. Two planned subgroup analyses will explore the influence of first provider intubation competence and patients' baseline lung disease using pre-intubation respiratory support as a proxy.

ETHICS AND DISSEMINATION

The Institutional Review Boards at the Children's Hospital of Philadelphia and the University of Pennsylvania have approved the study. Upon completion of the trial, we intend to submit our primary results to a peer review forum after which we plan to publish our results in a peer-reviewed paediatric journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05451953).

Safe in the first attempt: teaching neonatal airway management

PURPOSE OF REVIEW

Quick and precise facemask ventilation and tracheal intubation are critical clinical skills in neonatal airway management. In addition, this vulnerable population requires a thorough understanding of developmental airway anatomy and respiratory physiology to manage and anticipate potential airway mishaps. Neonates have greater oxygen consumption, increased minute ventilation relative to functional residual capacity, and increased closing volumes compared to older children and adults. After a missed airway attempt, this combination can quickly lead to dire consequences, such as cardiac arrest. Keeping neonates safe throughout the first attempt of airway management is key.

RECENT FINDINGS

Several techniques and practices have evolved to improve neonatal airway management, including improvement in neonatal airway equipment, provision of passive oxygenation, and closer attention to the management of anesthetic depth. The role of nontechnical skills during airway management is receiving more recognition.

SUMMARY

Every neonatal intubation should be considered a critical event. Below we discuss some of the challenges in neonatal airway management, including anatomical and physiological principles which must be understood to approach the airway. We then follow with a description of current evidence for best practices and training.

Review Airway management in pediatric patients with burn contractures of the face and neck

Burn injury is a common cause of trauma, non-fatal burn injuries are a leading cause of morbidity, and significant numbers of the victims are children. Scar contracture after burn injury can cause severe functional limitation, pain, aesthetic and psychological problems and patients may present for contracture release and reconstructive surgery. The aim of this systematic review was to identify research relevant to airway management of children with burn contracture of the face and neck with special emphasis on awake airway management and airway anesthesia, and synthesize results that can aid practice. Literature search was performed on Medline, PubMed, Cochrane Library, and Google Scholar with selected keywords. The search was restricted to human subjects of ≤18 year age, there was no language or time restriction and the final search was concluded in July 2021. The review included 41 articles involving airway management of 56 patients in 61 anesthesia episodes. Patients aged between 8 months to 18 years. Mask ventilation and direct laryngoscopy, video laryngoscopy, optical stylet, supraglottic airway, flexible scope intubation and tracheostomy, and extracorporeal membrane oxygenation were the devices and methods used for securing the airway and oxygenation while the patients were awake or after anesthesia induction. Detailed planning and patient preparation are the fundamentals of airway management of pediatric patients with burn contracture of the face and neck, awake airway management with airway anesthesia can be safely used in selected patients, this review provides information for good clinical practice and might serve to improve the care of such children.

Continuous positive airway pressure to reduce the risk of early peripheral oxygen desaturation after onset of apnoea in children: A double-blind randomised controlled trial

Continuous positive airway pressure (CPAP) during anaesthesia induction improves oxygen saturation (SpO₂) outcomes in adults subjected to airway manipulation, and could similarly support oxygenation in children. We evaluated whether CPAP ventilation and passive CPAP oxygenation in children would defer a SpO₂ decrease to 95% after apnoea onset compared to the regular technique in which no positive airway pressure is applied. In this double-blind, parallel, randomised controlled clinical trial, 68 children aged 2–6 years with ASA I–II who underwent surgery under general anaesthesia were divided into CPAP and control groups (n = 34 in each group). The intervention was CPAP ventilation and passive CPAP oxygenation using an anaesthesia workstation. The primary outcome was the elapsed time until SpO₂ decreased to 95% during a follow-up period of 300 s from apnoea onset (T1). We also recorded the time required to regain baseline levels from an SpO₂ of 95% aided by positive pressure ventilation (T2). The median T1 was 278 s (95% confidence interval [CI]: 188–368) in the CPAP group and 124 s (95% CI: 92–157) in the control group (median difference: 154 s; 95% CI: 58–249; p = 0.002). There were 17 (50%) and 32 (94.1%) primary events in the CPAP and control groups, respectively. The hazard ratio was 0.26 (95% CI: 0.14–0.48; p<0.001). The median for T2 was 21 s (95% CI: 13–29) and 29 s (95% CI: 22–36) in the CPAP and control groups, respectively (median difference: 8 s; 95% CI: -3 to 19; p = 0.142). SpO₂ was significantly higher in the CPAP group than in the control group throughout the consecutive measures between 60 and 210 s (with p ranging from 0.047 to <0.001). Thus, in the age groups examined, CPAP ventilation and passive CPAP oxygenation deferred SpO₂ decrease after apnoea onset compared to the regular technique with no positive airway pressure.

Effect of positive end-expiratory pressure during anaesthesia induction on non-hypoxic apnoea time in infants: A randomised controlled trial

BACKGROUND

Hypoxaemia occurs frequently in infants during anaesthetic induction.

OBJECTIVE

We evaluated the effect of positive end-expiratory pressure during anaesthesia induction on nonhypoxic apnoea time in infants.

DESIGN

Randomised controlled trial.

SETTING

Tertiary care children's hospital, single centre, from November 2018 to October 2019.

PATIENTS

We included patients under 1 year of age receiving general anaesthesia.

INTERVENTION

We assigned infants to a 7 cmH2O or 0 cmH2O positive end-expiratory pressure group. Anaesthesia was induced with 0.02 mg kg-1 atropine, 5 mg kg-1 thiopental sodium and 3 to 5% sevoflurane, and neuromuscular blockade with 0.6 mg kg-1 rocuronium. Thereafter, 100% oxygen was provided via face mask with volume-controlled ventilation of 6 ml kg-1 tidal volume, and either 7 cmH2O or no positive end-expiratory pressure. After 3 min of ventilation, the infants' trachea was intubated but disconnected from the breathing circuit, and ventilation resumed when pulse oximetry reached 95%.

MAIN OUTCOME MEASURE

The primary outcome was nonhypoxic apnoea time defined as the time from cessation of ventilation to a pulse oximeter reading of 95%, whereas the secondary outcome was the incidence of significant atelectasis (consolidation score ≥2) assessed by lung ultrasound.

RESULTS

Sixty patients were included in the final analysis. Apnoea time in the 7 cmH2O positive end-expiratory pressure group (105.2 s) increased compared with that in the control group (92.1 s) (P = 0.011, mean difference 13.0 s, 95% CI, 3.1 to 22.9 s). Significant atelectasis was observed in all patients without positive end-expiratory pressure and 66.7% of those with 7 cmH2O positive end-expiratory pressure (P = 0.019, 95% CI, 1.7 to 563.1, odds ratio 31.2).

CONCLUSION

Positive end-expiratory pressure during anaesthesia induction with face mask ventilation increased nonhypoxic apnoea time in infants.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, NCT03540940.

Sustained pharyngeal inflation on upper airway effects in children-Flexible bronchoscopy measurement

OBJECTIVE

Sustained pharyngeal inflation (SPI) with pharyngeal oxygen and nose-closure (PhO₂ -NC) can create positive peak inflation pressure (PIP) inside the pharyngolaryngeal space (PLS). This study measured and compared the effects of four different SPI durations in the PLS.

METHODS

A prospective study, 20 consecutive children aged between 6 months and 3 years old, scheduled for elective flexible bronchoscopy (FB) suspected positive PLS findings were enrolled. SPI was performed twice in four different durations (0, 1, 3, and 5 s) sequentially in each infant. PIP was measured for each SPI in the pharynx, while simultaneously record images at two locations of the oropharynx and supra-larynx. Patient demographic details, PIP levels, lumen expansion scores, and images of PLS were measured and analyzed.

RESULTS

Twenty patients with 40 measurements were collected. The mean (SD) age and weight were 11.6 (9.1) months and 6.8 (2.4) kg, respectively. The measured mean (SD) pharyngeal PIPs were 4.1 (3.3), 21.9 (7.0), 42.2 (12.3), and 65.5 (18.5) cmH₂ O at SPI duration of 0, 1, 3, and 5 s, respectively, indicating significant (p<.001) positive correlation. At assigned locations, corresponding PLS images also displayed a significant increase in lumen expansion scores and a number of detected lesions with an increase in SPI duration (p < .004). The mean (SD) procedural time was 5.7 (1.2) min. No study-related complication was noted.

CONCLUSIONS

FB utilizing PhO₂ -NC as SPI of 1-3 s is a simple, less invasive, and valuable ventilation modality. It provides an adequate PIP level to expand the PLS and improve FB performance in children.

Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy

BACKGROUND

In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI).

METHODS

The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [Spo2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared.

RESULTS

A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%-37%]; mRSI, 17% [10%-24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5-5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8-22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0-22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7-40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%).

CONCLUSIONS

In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.

Vallecular cyst with coexisting laryngomalacia: Successful diagnosis and laser therapy by flexible endoscopy with a novel noninvasive ventilation support in infants

OBJECTIVE

Vallecular cyst coexisting with laryngomalacia (VC-LM) can cause significant pharyngolaryngeal obstruction. Traditionally, it is diagnosed with flexible endoscopy (FE) and treated by rigid endoscopy. This study evaluates the effectiveness of solely using FE with novel noninvasive ventilation (NIV) of sustained pharyngeal inflation (SPI) support for both diagnosis and treatment in such infants.

METHODS

A retrospective review of consecutive infants who were diagnosed and treated for VC-LM in the 12-year period, 2007 to 2018, was conducted. Clinical variables, techniques, and outcomes were analyzed and reported.

RESULTS

Eighteen infants (10 males) were included. The mean age was 3.0 ± 0.6 months and the mean body weight was 4.6 ± 1.3 kg. Before FE, 14 infants were supported with bi-nasal prongs NIV (BN-NIV) and four infants with tracheal intubation. During diagnostic and therapeutic FE, all infants supported with a nasopharyngeal NIV (NP-NIV) only. All diagnoses were made in the first FE inspection of 3.5 ± 1.2 minutes. Thirteen lesions were immediately treated with FE laser therapy in 18.1 ± 1.7 minutes in the same FE course. Total FE time was 24.6 ± 2.8 minutes. Three infants needed revision laser therapy 4 days later. There was no desaturation (<90%), bradycardia (<100/min), or pneumothorax. After FE therapy, all infants were supported with BN-NIV only with significantly (<0.01) lower pressure and completely weaned off before being discharged 8.4 ± 1.5 days later. All infants, followed up for a 6-month period, showed many clinical improvements.

CONCLUSIONS

FE, with this NP-NIV and SPI supports, could offer accurate diagnosis and successful laser therapy of the VC-LM with procedural sedation in the same session in infants.

Apnoeic oxygenation in paediatric anaesthesia: a narrative review

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.

Emerging trends, techniques, and equipment for airway management in pediatric patients

Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.

The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel

Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient’s death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.

Survival Analysis and Interpretation of Time-to-Event Data: The Tortoise and the Hare

Survival analysis, or more generally, time-to-event analysis, refers to a set of methods for analyzing the length of time until the occurrence of a well-defined end point of interest. A unique feature of survival data is that typically not all patients experience the event (eg, death) by the end of the observation period, so the actual survival times for some patients are unknown. This phenomenon, referred to as censoring, must be accounted for in the analysis to allow for valid inferences. Moreover, survival times are usually skewed, limiting the usefulness of analysis methods that assume a normal data distribution. As part of the ongoing series in Anesthesia & Analgesia, this tutorial reviews statistical methods for the appropriate analysis of time-to-event data, including nonparametric and semiparametric methods—specifically the Kaplan-Meier estimator, log-rank test, and Cox proportional hazards model. These methods are by far the most commonly used techniques for such data in medical literature. Illustrative examples from studies published in Anesthesia & Analgesia demonstrate how these techniques are used in practice. Full parametric models and models to deal with special circumstances, such as recurrent events models, competing risks models, and frailty models, are briefly discussed.

High-flow nasal oxygenation for anesthetic management

High-flow nasal oxygenation (HFNO) is a promising new technique for anesthesiologists. The use of HFNO during the induction of anesthesia and during upper airway surgeries has been initiated, and its applications have been rapidly growing ever since. The advantages of this technique include its easy set-up, high tolerability, and its abilities to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide to some extent. HFNO, via a nasal cannula, can provide oxygen both to patients who can breathe spontaneously and to those who are apneic; further, this technique does not interfere with bag-mask ventilation, attempts at laryngoscopy for tracheal intubation, and surgical procedures conducted in the airway. In this review, we describe the techniques associated with HFNO and the advantages and disadvantages of HFNO based on the current state of knowledge.

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs

OBJECTIVES

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.

DESIGN

Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.

SETTING

International PICUs.

PATIENTS

Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.

INTERVENTIONS

tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.

MEASUREMENTS AND MAIN RESULTS

A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001).

CONCLUSIONS

In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

Haemodynamic response and effectiveness of tracheal intubation with Airtraq® versus Macintosh laryngoscope in paediatric patient undergoing elective surgery: Prospective, randomised and blind clinical trial

OBJECTIVE

To compare the haemodynamic response and effectiveness of tracheal intubation with Airtraq® device and Macintosh laryngoscope, for airway management of patients between 2 and 8 years undergoing elective surgery.

METHODS

A prospective, comparative, randomised and blind clinical trial where the effectiveness of tracheal intubation in 80 paediatric patients undergoing elective surgery was determined. Patients were divided into 2 groups of 40 subjects each: group A, intubated with Airtraq® optical laryngoscope; and group M, intubated with Macintosh laryngoscope. Haemodynamic changes, time and number of attempts at intubation and its complications were evaluated in both.

RESULTS

Heart rate was higher in group M from minute 1 to 5 with statistically significant difference (p: .001). The mean, systolic and diastolic blood pressure and EtCO₂ values were higher in group M. There were no statistically significant differences in SO₂. There was a statistically significant difference in time (group A: 18 ± 4seconds, group M: 27 ± 7seconds) and the number of attempts for intubation were lower for group A (p: .001). Seven patients in group M had post-intubation complications while only one subject had in group A.

CONCLUSION

Intubation with Airtraq® device is more effective than Macintosh laryngoscope in terms of reduction of haemodynamic changes, SO₂, EtCO₂, time and number of attempts for intubation and complications in paediatric patients undergoing elective surgery.