PRACTICAL PROCEDURES – AIRWAY AND BREATHING

the tube too far, thereby avoiding inadvertent bronchial intubation, it is much, much more dangerous to have a tube which is too short as this may be displaced any time by movement of the child’s head. 6. Following intubation, placement of the tube should be con1rmed by both inspecting the chest for equal bilateral movement and by auscultating the chest. It is also worth listening over the epigastrium for the absence of classic borborygmi following oesophageal intubation. 7. If intubation is not achieved within 30 seconds discontinue the attempt, re-establish preoxygenation and try again. 8. The de1nitive test for successful placement is the presence of expired CO2 in the exhaled air. This can be tested by either chemical colour-change devices or even better, by de1nitive endtidal CO2 measurement. This is not yet accepted in neonates. A large randomised trial is underway. 9. Inflate the cuff if present, to provide an adequate seal. Note, however, that cuffed tubes should only be used in infants and small children when vital, i.e. with “stiff” lungs and by those who are trained and experienced in their use. 10. Once the tube is inserted and 1xed into place, arrangements should be made to obtain a chest X-ray to con1rm correct tube length. The end of the tube on X-ray should be below the level of the vocal cords, but above the carina.

Older child 1. Ensure that adequate ventilation and oxygenation by face mask are in progress. 2. Prepare and check equipment. (before inducing RSI if used under these circumstances) 3. Select an appropriate tube size, but prepare a range of sizes, including the size above and below the best estimate (see Chapter 5). 4. Ensure manual immobilisation of the neck of cervical spine injury by an assistant is possible. 5. Hold the laryngoscope in the left hand and insert it into the right-hand side of the mouth, displacing the tongue to the left. 6. Visualise the epiglottis and place the tip of the laryngoscope anterior to it in the vallecula. The epiglottis is then pulled forwards by anterior pressure in the vallecula as demonstrated in the illustration. 7. Gently but 1rmly lift the handle towards the ceiling on the far side of the room, while being careful not to lever on the teeth (Figure 20.5). 8. Insert the endotracheal tube into the trachea, concentrating on how far the tip is being placed below the vocal cords. The tip should lie at least 2 cm below the vocal cords, depending on age. If the tube has a “vocal cord level” marker, place this at the vocal cords. Be aware that Eexion or extension of the neck may cause migration downwards or upwards, respectively. 9. InEate the cuff if present, to provide an adequate seal. 10. Check the placement of the tube by inspecting the chest for movement and auscultating the chest (including the axillae) and epigastrium. 11. If endotracheal intubation is not achieved in 30 seconds, discontinue the attempt, ventilate and oxygenate by mask and try again. 12. Monitor expired carbon dioxide in the exhaled air by either colour-change capnometry or end-tidal capnography. 13. Once the tube is in place obtain a chest X-ray to con1rm correct placement. Complications of endotracheal intubation These include: • Oesophageal intubation – This is the most dangerous complication of attempted intubation. Will cause severe hypoxia if not immediately recognised and is particularly dangerous when it occurs secondary to tube misplacement. • Endobronchial intubation, resulting in lung collapse and/or risk of pneumothorax.

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• • •

Subglottic oedema or stenosis Oesophageal perforation Infection

20.6 VENTILATION WITHOUT INTUBATION Mouth-to-mask ventilation 1. Apply the mask to the face, using a jaw thrust grip, with the thumbs holding the mask. If using a shaped mask, it should be the right way up in children (Figure 20.9), or upside down in infants (Figure 20.10). 2. Ensure an adequate seal. 3. Blow into the mouth port, observing the resulting chest movement. 4. Ventilate at an initial 12-20 breaths/min, depending on the age of the child if the child is apnoeic or is hypoventilating. If using the mask for CPR then use two ventilations to 15 compressions. 5. Attach oxygen to the face mask if possible.

Figure 20.9. Mouth-to-mask in a child

Figure 20.10. Mouth-to-mask in an infant

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PRACTICAL PROCEDURES – AIRWAY AND BREATHING

Bag-and-mask ventilation 1. Apply the mask to the face, using a jaw thrust grip. The fourth and 1fth 1ngers should perform a jaw thrust and the other 1ngers hold the mask tightly in place (Figure 20.11). 2. Ensure an adequate seal. 3. Squeeze the bag observing the resulting chest movement. 4. Ventilate at an initial 12-20 breaths/min, depending on the age of the child if the child is apnoeic or is hypoventilating. If using the bag and mask for CPR then use two ventilations to 15 chest compressions.

Figure 20.11. Bag-and-mask ventilation

If a two-person technique is used, one rescuer maintains the mask seal with both hands, while the second person squeezes the self-in,ating bag. This is to be recommended

20.7

MANAGEMENT OF BLOCKED TRACHEOSTOMY FOR FIRST RESPONDER HEALTH PROFESSIONALS

When you suspect a child with the tracheostomy tube is not breathing, the procedure to follow is:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Stimulate Shout for help Suction Check for breathing – IF NOT BREATHING Tube change Check for breathing Give 5 breaths if not breathing Check pulse/signs of circulation If no signs of circulation, start CPR with a ratio of 15 chest compressions to 2 ventilations After 1 minute summon help if none available yet

Do not leave the child alone if his or her breathing returns to normal

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PRACTICAL PROCEDURES – AIRWAY AND BREATHING

Basic Life Support 1. Stimulate the child 2. Shout for help 3. Open and check the airway, extend the neck with a head tilt. This exposes the tracheostomy tube (Figure 20.12). You may need to lift the chin also to expose the tracheostomy tube completely. If the tube is blocked attempt to clear it with a suction catheter if you are unable to pass the suction catheter down the tracheostomy tube – then the tube must be changed immediately.

Figure 20.12. Chin lift

If you are unable to insert the new tube: – try a smaller tube; if unable to insert this – thread a suction catheter through the tracheostomy tube. Insert the tip of the suction catheter into the stoma, then attempt to guide the tracheostomy tube along the catheter and into the stoma. – If this is unsuccessful then: attempt breathing via the suction catheter through the stoma (only if a large suction catheter) or attempt mouth-to-stoma/mouth-to-mouth resuscitation.

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PRACTICAL PROCEDURES – AIRWAY AND BREATHING

Figure 20.13. Check for breathing

4. Check for breathing. Supporting the new tube, place the side of your face over the tracheostomy tube to listen and feel for any breaths, and at the same time look at the child’s chest to observe any breathing movement (Figure 20.13). If the child is breathing satisfactorily, secure the tracheostomy tube, place him in a recovery position and continue to assess him. If the child is not breathing, or there are only infrequent gasps, you will have give rescue breaths. 5. Give 1ve rescue breaths. Cover the child’s tracheostomy tube with your mouth and exhale to make the chest rise. Remove your mouth from the child’s tube to let the breath escape from their lungs. Repeat this 1ve times at a rate of about one breath, every 2 seconds. You will know your breathing has been effective if you can see the child’s chest rise and fall with each breath. After 1ve breaths of mouth-to-tracheostomy rescue breathing, you must check to see whether or not the child has a pulse, or any other signs of circulation. 6. If there is no pulse present or you are not sure and the child has not moved or responded to the rescue breathing with a cough or gasp, you will need to perform chest compressions as well as provide the child with rescue breathing. 7. Chest compressions should compress the lower third of the sternum. The finger/thumb or hand position for all ages is found by finding the angle where the lowest ribs join in the middle at the xiphisternum and placing the finger/thumb or hand one finger’s breadth above this. The rate for chest compressions is 100 per minute. Using two fingers for an infant and one or two hands for a child, compress the lower third of the sternum 15 times by one third of the diameter of the chest then give two ventilations. If possible, support the trachestomy tube with the free hand, if one is available. 8. Give one minute of fifteen chest compressions to two breaths and then call for help. If the child recovers, place them in the recovery position, and continue to assess and support.

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Emergency equipment for tracheostomy change This should be checked daily 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Usual-size tracheostomy tube with tapes attached Smaller-size tracheostomy tube with tapes attached Scissors Sterile sodium chloride 0.9% ampoules Five 2-ml syringes Tracheal dilators Spare tape Gauze swab KY Jelly Gloves

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