North West Neonatal Operational Delivery Network (NWNODN ... · Providers of neonatal care in the North West Neonatal Operational Delivery Network. Implementation: All providers must

Title North West Neonatal Operational Delivery Network (NWNODN) Difficult Airway Guideline

Reference Number GL-ODN-06

Author

North West Difficult Airway Interest Group:

Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr

M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F

Paize, Dr I Dady.

With contribution from Dr Alok Sharma from Southampton.

Emma Kyte & Kelly Harvey– Quality Improvement Lead Nurses,

NWNODN

Target Audience All Provider Trusts within the North West Neonatal Operational

Delivery Network

Ratified by All locality NSG’s

Date ratified 11/10/2018

Review date 11/10/2021

Version 4 – Final

Document status Shared via CEGs

Document History:

Date Version Author Notes

15/3/2018 1 Difficult Airway SIG Final version algorithm complete

Oct 2018 2 E. Kyte Referral pathway added

11/10/2018 3 K. Harvey Equipment guidance added and

reformatted to NWNODN guidline

30/7/2019 4 K.Harvey

Front page amended by CN to use standard template. Review date extended. All guidelines to be reviewed every 3 years unless rational for earlier review.

North West Neonatal Operational Delivery Network

Difficult Airway Guideline

Introduction: Neonatal services aim to deliver a high quality safe effective service for premature and sick newborns and their families. Services within the North West are provided within three localities, Lancashire & South Cumbria, Cheshire & Merseyside and Greater Manchester which form the North West Neonatal Operational Delivery Network (NWNODN). It is recognised that an infant presenting with a difficult airway within a neonatal unit requires swift, effective management. This guideline aims to provide a standardised approach to airway management when a difficult airway is suspected or confirmed. This approach is supported by a detailed algorithm and information regarding equipment required. Purpose: To standardise the clinical management of a difficult airway and the equipment required to support this approach. The pathway for referral is documented for continued management of such cases. Scope: Providers of neonatal care in the North West Neonatal Operational Delivery Network. Implementation:

All providers must organise locally how elements of the algorithm will be supported. In

particular it is recommended all providers contact their local anaesthetist colleagues and

ensure they are aware of the process should a difficult airway arise. The contact

number/bleep for the local team should be displayed alongside the algorithm.

All referrals for advice or transfer regarding a neonate with a confirmed or suspected

difficult airway must be made through the North-west Cot bureau: 0300 330 9299.

Following referral the Cot bureau will set up a conference call where necessary, find a bed

and liaise with the appropriate transport team according to the pathway below:

NWNODN Difficult Airway Pathway for Transfer:

All infants >34/40 and /or > 2Kg will be transferred by the North West Paediatrics

Transport Service (NWTs).

All infants <34/40 and /or <2Kg will be transferred by Connect North West (Neonatal

transport service).

In some clinical situations it maybe appropriate for:

Both transfer teams to attend a referring hospital

Both transport teams to hold a joint conference call to develop a management plan

for complex patients or those which fall close to the criteria set above.

Guidance on Equipment requirements:

All equipment detailed within the algorithm may not be required in all providers. The following is a guide to support implementation of the guideline and individual providers should assess equipment requirements within their own unit based upon skills and competence of the clinical team.

All providers should have the equipment details within the standard airway management kit.

All providers should have items 1-6 inclusive from the advanced airway management kit.

It is recommended that all units have a video-laryngoscope available for the management of a difficult airway and for training purposes. This should be locally agreed.

Only those units with staff trained in the use of Brambrink/Hopkins rod should have these available.

It is recommended the Quicktrach is available in all units due to its potential lifesaving value when all else fails.

The Surgical tracheostomy kit is only required in units with immediate access to ENT surgeons and should be agreed locally alongside local ENT teams.

Practical Application:

The algorithm below should be displayed and easily available within all neonatal providers.

It is recommended that a difficult airway kit is clearly labelled and easily accessible to support management in an emergency situation.

Follow the algorithm to determine which clinical scenario the infant is in and utilise the supportive guide for continued management.

Neonatal Airway Management Algorithm: By North West Difficult Airway Interest Group

(Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F Paize, Dr I Dady)

With contribution from Dr Alok Sharma from Southampton

Yes

No

Chest inflation difficult despite good position

and mask seal

Maintain airway & Oxygenation (PEEP/CPAP as indicated)

Has the chest moved?

Adequate respiratory effort

Neonatal Airway Management Algorithm

Newborn in need of respiratory support

No

Intubation successful With colour change on

End tidal CO2 device

Yes

HR >100

Yes

No

Follow NLS

algorithm

Intubation unsuccessful or

difficult

Refer Difficult Intubation

guidance next page

Standard NLS approach Dry and wrap, start clock, assess

Open airway, 5 inflation breaths,

Neutral head position/Shoulder roll Consider: 2-handed jaw thrust

Suction under direct vision Oro-pharyngeal airway – consider Sats/ECG

Decision to intubate - Think of support needed if you fail

Take following action based on clinical situation 1. Ensure ETT not in too far, adjust length appropriately for

baby’s weight 2. Increase pressures to overcome stiff lung 3. Suction below cords to remove any thick mucus/ meconium

plug

CAN INTUBATE BUT CAN’T VENTILATE SCENARIO

Intubation done BUT no chest rise or

colour change on End

tidal PCO2

Neonatal Airway Management Algorithm: By North West Difficult Airway Interest Group

(Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F Paize, Dr I Dady)

With contribution from Dr Alok Sharma from Southampton

CAN’T INTUBATE BUT CAN VENTILATE SCENARIO

CAN’T INTUBATE BUT CAN VENTILATE SCENARIO

CAN’T INTUBATE & CAN’T VENTILATE SCENARIO

(Airway atresia,

very tight sub-glottic stenosis, haemangioma, laryngeal web etc.)

Plan D

Rescue Techniques

REQUEST ENT HELP (REFER TO LOCAL ARRANGEMENTS)

ENT HELP TIMELY AVAILABLE ENT HELP TIMELY NOT AVAILABLE

Consider following (depending on time / skills / equipment): a) Direct tracheostomy b) Rigid bronchoscopy & intubate via scope

UNABLE TO OXYGENATE

SURGICALTRACHEOSTOMY

Plan A

Initial intubation

attempts

Plan B

Oxygenation and

secondary intubation

Plan C

Intubation using special

equipment

If no local expertise / no advanced intubation equipment available and able to oxygenate baby, liaise with Transport team to arrange transfer of baby on LMA to Regional Centre

If successful intubation, Confirm ET tube placement

clinically &

by colour change capnography

or colorimetric CO2 detector

Refer RED TEXT BOX overleaf for more information on local /regional

arrangements with ENT team and training recommendations for these

rescue techniques

Think of the situation and possible solutions with priority to keep baby oxygenated Anticipate airway difficulty and request Anaesthetic/ENT help Refer AMBER TEXT BOX overleaf

INTUBATION DIFFICULT? CALL FOR HELP

If senior member of the neonatal team is experiencing difficulties intubating a crash call for the consultant needs to be put out as a priority. Please consider the following whilst waiting for assistance:

If help delayed, Try LMA (for babies >1.8kg)

At birth, maternity anaesthetist may be available as immediate source of help

Ask for Difficult Airway Kit awaiting help arrival

Place NG tube to deflate stomach

Maintain oxygenation throughout

Use LMA to oxygenate (For babies >1.8 Kg)

If 3 LMA attempts not successful

CONSIDER:

Video Laryngoscope guided intubation

Seldinger technique intubation using neonatal

Bougie

Seldinger technique intubation using Brambrink

intubation endoscope (if trained to use this)

Think of the situation, reason for failure & possible solutions. Priority is to oxygenate baby awaiting Consultant arrival. Refer YELLOW TEXT BOX overleaf

Baby <1.8 Kg, If intubation not

successful

Two further intubation attempts by Consultant If Consultant fails to intubate in 2 attempts

Maintain oxygenation throughout (try LMA if

help delayed)

Switch back to face mask ventilation &

Following oxygenation, further attempt at intubation with advanced skills/equipment

Percutaneous cannula tracheotomy Wide bore eg Quicktrach infant 1.5mm

(standard 15mm connector allowing to give

IPPV) OR 16 G Grey Venflon (Only high flow O2 can be delivered) With use of Enks oxygen flow meter

Neonatal Airway Management Algorithm: By North West Difficult Airway Interest Group

(Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F Paize, Dr I Dady)

With contribution from Dr Alok Sharma from Southampton

CAN’T INTUBATE BUT CAN VENTILATE Priority: Oxygenate baby using 100% oxygen

Think of possible solutions below, appropriate to the problem

Anticipate airway difficulty and request Anaesthetic/ENT help as per local arrangements Difficult larynx view – no or partial view laryngeal view with conventional laryngoscope 1. Cricoid pressure may help 2. Try LMA (i-gel) size 1 [for babies >1.8kg] 3. Video laryngoscope assisted intubation; better larynx view than conventional laryngoscope (Where available, by trained personnel) 4. Seldinger technique of intubation with help of Neonatal Bougie and video laryngoscope (Where available, by trained personnel) 5. Seldinger technique of intubation with BRAMBRINK endoscope (Where available and by trained personnel) Narrow airway (anatomic abnormality, sub glottis stenosis)

1. Use size 2.0 ETT 2. Seldinger technique of intubation using video laryngoscope* (where available, by trained personnel)

3. Seldinger technique of intubation with BRAMBRINK endoscope (where available, by trained personnel)

CAN’T INTUBATE AND CAN’T VENTILATE

Quicktrach use can have serious complications and training is required, at least in simulation setting. (One may never see such situations in their life time career). Only use these techniques in life threatening situations where there is no other way of oxygenating and keeping baby alive.

Once expert ENT help arrives, convert to a definitive airway as soon as possible.

Local ENT contact numbers for emergencies: ---------------------------------------------------------------------

Regional ENT contact numbers for emergencies: ----------------------------------------------------------------

INITIAL FAILED INTUBATION ATTEMPTS BY REGISTRAR (MAXIMUM 2 FURTHER ATTEMPTS) Priority: Oxygenate baby using 100% oxygen

Think of possible solutions below appropriate to the problem and act whilst awaiting help

Request Difficult Airway kit awaiting Consultant arrival

Poor view: Cricoid pressure & appropriate head position may improve visualisation allowing intubation /partial

view allowing bougie guided intubation

Preterm baby – Baby spontaneously breathing: Let baby breathe spontaneously and give IPPV/PEEP with oxygen as required, insert NGT to deflate stomach, keep baby warm and wait for help

Micro-premie baby (<500grams– Baby spontaneously breathing: Provide PEEP and then try intubation

with smaller Size 000 blade and size 2.0 ETT (will need opening of difficult airway kit)

Micrognathia – Baby spontaneously breathing,

.Ask yourself the question – does this baby need intubation? a) Position: Place baby in prone/lateral position and give O2 b) Airway Adjunct: Try Nasopharyngeal airway and give O2

Microstomia – Baby spontaneously breathing,

. Try Naso-Pharyngeal airway and give O2 Macroglossia – Baby spontaneously breathing,

a) Try Naso-Pharyngeal airway and give O2 b) Try broader curved blade to clear the tongue to help intubation

Use of LMA: For babies >1.8 kg, consider LMA if unable to visualise larynx

Neonatal Airway Management Algorithm: By North West Difficult Airway Interest Group

(Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F Paize, Dr I Dady)

With contribution from Dr Alok Sharma from Southampton

List of standard Airway equipment

Item Description/picture/comment

1 Self-inflating resuscitation bag

2 Masks of different sizes

(Right size mask is one that appropriately fits baby face– covers mouth and nose but does not press on eyes.

Also preferable to have Micro –premature and premature masks as these fits well for very small premature babies to prevent leak (Fisher & Paykel or similar size from another manufacturer).

3 Guedel airways of various sizes

– 000, 00, 0,1 Measure airway from centre of lips to angle of mandible with convex side facing upwards

4 Laryngoscope (straight blade) – Size 00, 0, 1

As a guide use size 00 for <1kg, size 0 for 1-2 kg and size 1 for >2kgs

5 Laryngoscope handle (x2) Laryngoscope handles same make to fit blades of all sizes

6 Batteries x 4 Spare batteries always in the kit for laryngoscope handles

7 End tidal CO2 detector To confirm ETT placement in trachea– colour change from Purple to Yellow implies ETT in trachea. Pedicap end tidal CO2 detector (for babies 1.0-15.0kg) Neostat end tidal CO2 detector (for babies 0.25-6.0kg)

8 Yanker sucker

Thick meconium/large blood clot / secretions plug - will need Yanker sucker to clear the airway

9 Black large bore suction catheter

There is no role of suction catheter other than Black catheter at resuscitation, as others will be too small to clear the airway

10 Nasogastric tube and 10mls feeding syringe

To deflate the stomach

11 ET Tube size: 2.0mm 2.5mm, 3.0mm, 3.5mm, 4.0mm

As a guide use size 2.5 for <1kg, size 3.0 for 1-2 kgs, size 3.5 for 2- 4kgs and size 4 for > 4kgs

12 ET tube fixation kit – clamp/neobar

Ensure appropriate fixation kit present to secure the ETT

13 Introducer for ET tube

Ensure it goes to tip of ETT but does not protrude beyond ETT (to prevent damage to the airways).

14 Cap(hat) of various sizes to secure ETT along with ties

Where Neobar is not used as fixation kit, one would need appropriately fitting cap/hat. This could be knitted hat or CPAP hat of appropriate size. Appropriate length ties to secure ETT will also be needed

16 Laryngeal Mask Airway (LMA) size 1 ( i Gel )

Use of iGel or LMA size 1 where difficulty in chest inflation despite use of NLS protocol

17 Scissors

To cut the ties during securing of ETT or for adjusting ETT length after securing the ETT

18 Clamp Artery forceps clamp to tighten the ETT clamp (where applicable)

Neonatal Airway Management Algorithm: By North West Difficult Airway Interest Group

(Dr N B Soni, Dr R Narasimhan, Dr R Gupta, Dr A Cox, Dr L Bowden, Mr M Rothera, Ms M Sadadcharam, Ms S Schaefer, Mr A Daudia, Dr F Paize, Dr I Dady)

With contribution from Dr Alok Sharma from Southampton

Difficult Airway Kit ( items additional to standard airway management kit)

1 Laryngeal Mask Airway (LMA) size 1 ( i Gel )

Use of iGel /LMA size 1 for babies more than 2.0kg ( can be tried in from 1.8kg onwards) if difficulty in intubation and awaiting help from expert help.

2 Laryngoscope straight blade size 000 with its specific handle and AA Batteries

Useful for babies with small mouth ( ≤ 500 grams)

3 Laryngoscope curved blade size 1

Sometimes curved blade gives better clearance of tongue to have better view of the larynx. Ensure blade fixes with the same handle used for standard straight blades.

4 ET Tube size 2.0 Where one is struggling to intubate and unable to insert bigger ETT tube – size 2.0 can be used until reviewed by experienced specialist

5 Macgill forceps To help guide ET tube in some cases

6 Bougie for intubation (Tracheal Tube Guide 5F) Seldinger technique intubation by trained personnel ( where available)

If tracheal opening is very narrow or partially visible– bougie can be used as a guide to intubate using Seldinger technique. Also where already airway is diagnosed to be difficult and change of ETT is required, bougie can be used to electively change or upsize the ETT ( to be used by trained personnel)

7 CMAC/Infant-view Video laryngoscope by trained personnel ( where available)

Use of CMAC/Infant-view video-laryngoscope gives much better view of airway and can be used to help intubate baby. This is also useful for teaching trainees to intubate.

8 BRAMBRINCK retromolar Intubation Endoscope for Seldinger technique intubation by trained personnel (where available) )

ONLY to be used by trained personnel. It is similar to bougie intubation in form of Seldinger technique, except that this has a built in light source and it is rigid.

9 Quicktrach (Emergency Cricothyrotomy kit) by trained personnel (where available) )

Only to be used if severe airway obstruction and can’t intubate and can’t oxygenate using other techniques listed above and Surgical Tracheostomy facility not imminently available with no other way of keeping the baby alive.

10 Surgical Tracheostomy kit (ENT specialist use only)

after agreement with local or regional ENT team

This kit is kept ready for use if such a situation arises where surgical tracheostomy is required by ENT team to keep the airway patent. Components of kit to be agreed with local/regional ENT input.