Do drugs help? Rapid sequence intubation/rapid sequence airway technique has been used in anesthesia and emergency medicine for many years and is an option in some prehospital care systems as well. RSI/RSA involves pre-treating a patient with a combination of sedative and neuromuscular blocking agents or "paralytic" drugs intended to facilitate airway placement. The purpose of medications in RSI/RSA is to completely eliminate the patient's ability to resist intubation, voluntarily or involuntarily. Of course, this also means eliminating the patient's ability to breathe voluntarily or involuntarily. If all goes smoothly, this procedure is very useful. But these techniques are not without their own subset of risks and potential complications, which are increased in the unpredictable EMS setting or in patients with whom we are less comfortable or less familiar (e.g., pediatrics). While research on the use of RSI/RSA techniques in the prehospital setting is ongoing, the subject remains controversial.15-17
So, if our attempts at pediatric intubation don't appear to improve patient outcomes, even in a busy urban EMS system, what's the future direction for prehospital pediatric airway management?
"Endotracheal intubation is a motor skill that demands practice. EMS providers with limited intubation experience should consider using airway adjuncts other than ETI for respiratory compromise."18PEDIATRIC AIRWAY MANAGEMENT
For all prehospital providers, initial airway management in children includes three key elements: positioning (the patient), placement (of the equipment) and providing (supplemental oxygen). In addition to providing appropriate cervical spine precautions, proper positioning of pediatric patients involves remembering a very important principle: Small children have what we call "big head, little body syndrome." Simply stated, because of their relatively large occiput, infants and small children do not naturally assume a neutral position when supine. Placing a properly sized oral airway is the second key element. Nasal airways are generally too small and are easily clogged with secretions and mucus.6,19 The third element, providing effective bag-mask ventilation, may be the most difficult of the three. Some anesthesia and emergency medicine practitioners suggest that putting the tube in is often the easy part.7 Bagging a patient is a true art.
These techniques are essential for not only BLS providers, but emergency professionals at all levels. If pediatric airway management is needed, attention to these concepts will serve you and your patients well. Think about it: If a child is not breathing, what do you do before you tube? Ventilate. What do you do after you tube? Ventilate. What do you really have to do if you can't put the tube in? Ventilate. That's why bag-mask ventilation is so important. But the skill is not as easy to master as many imagine.
"A full stomach is probably the most common problem in pediatric anesthesia. Children can never be trusted to fast."20
Does bag-mask ventilation work? Yes and especially when a two-rescuer technique is paired with proper positioning and placement of an appropriately sized airway adjunct and mask.7 However, there are complications with bag-mask ventilation, the most notable being aspiration of stomach contents. Think of it as "Bellies + Bag-Mask = Barfing." We all know that from the mouth everything goes to either the lungs or the belly. If air, which belongs in the lungs, is introduced to the belly, or if stomach contents that belong in the belly are introduced to the lungs, trouble will surely follow. Ideally, the belly is empty and stays that way, and only air goes into the lungs through a perfectly placed ET tube. But we don't practice in an ideal world. Our patients, especially pediatric patients, are rarely without oral intake for 6 to 12 hours before we see them. So while proper positioning and placement of the oral airway help provide air to the proper area, more often than not, bag-mask ventilation will result in air being forced into the belly, which, unfortunately, is a recipe for aspiration.21,22
"We believe the time has come to carefully study the validity of the 'gold standard' assumption (prehospital intubation) and to evaluate the efficacy of alternative airway management."23
If we want to avoid the problems of bagging without an ET tube, and we know that prehospital pediatric intubation is not necessarily the answer (due to inconsistent results), is there a better way for BLS and ALS providers to maintain a pediatric airway? Absolutely, through the use of nonvisualized airways. In the prehospital environment, nonvisualized, or blindly inserted, airways had been limited to esophageal obturator airways (EOAs) or, more recently, the Combitube (see Figure 1). Combitube insertion has become widely accepted for BLS providers, and for ALS providers who, for whatever reason, determine that an endotracheal tube cannot be placed. The Combitube is blindly inserted into the mouth and usually ends up in the esophagus; however, in a small percentage of cases, blind tracheal placement can occur (see Figure 2).5