Safe in the first attempt: teaching neonatal airway management

Abstract

Purpose of reviewQuick 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 findingsSeveral 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.SummaryEvery 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.

Can video laryngoscopy and supplemental oxygen redefine pediatric, infant and neonatal tracheal intubation standards?

“…The importance of supplemental oxygenation through TI to maintain safety during TI attempts in neonates is also highlighted by Garcia-Marcinkiewicz and Matava in their review article, along with the need for anesthetic/sedation depth maintenance and adequate choice of devices and equipment. These authors also emphasize the importance of situational awareness and close attention to human factors ( 2 ). These recommendations are resumed and reinforced in the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia Guidelines on neonates’ and infants’ airway management ( 24 ).…”

“…Neonatal and young infants’ specific developmental airway anatomy and respiratory physiology features, such as high airflow resistance, high airway collapsibility, high oxygen consumption with increased metabolism, and low reserve, contribute to a higher risk for respiratory failure ( 1 , 2 ). Anesthesia and tracheal intubation (TI), added to their higher vulnerability to airway obstruction and lower apnea tolerance, may lead to oxygen desaturation and critical outcomes ( 1 , 2 ). Every neonatal intubation should be considered a critical event ( 2 ).…”

“…Anesthesia and tracheal intubation (TI), added to their higher vulnerability to airway obstruction and lower apnea tolerance, may lead to oxygen desaturation and critical outcomes ( 1 , 2 ). Every neonatal intubation should be considered a critical event ( 2 ). In pediatric and neonatal intensive care units (PICU and NICU, respectively) as well as pediatric emergency departments, clinical instability may add to the factors mentioned above, turning TI of critically ill patients into a high-risk procedure that can be associated with several adverse events ( 3 , 4 ).…”

“…Pediatric TI can present many challenges. Attention should be paid to the unique characteristics of pediatric and neonatal airways and respiratory physiology to prepare for potential adverse events specific to this population ( 1 , 2 , 24 ). The number of TI attempts matters, and achieving TI within a limited number of attempts relies on several factors beyond professional expertise.…”

Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway

“…The primary study outcome was first-attempt success of tracheal intubation, which is a clinically important outcome because multiple attempts at intubation are associated with worse outcomes in pediatric airway management. 1,7 Sequera-Ramos et al . 6 observed similar rates of first-attempt success of tracheal intubation in the propensity score-matched sedation and general anesthesia groups (48.3 and 47.9%, respectively).…”