Barely an airway in a decompensating premie

[Doc Dutch]

You are on-call all night and you get paged to the L and D suite emergently. There you find a mother who has just delivered a 32 week old premie. The nurse practitioner goes to intubate the premie due to a low APGAR and discovers that there is a mass off the left tongue which has grown into the roof of the mouth, occluding 2/3 of the oropharynx, with leftward tracheal deviation of the upper trachea by the cricoid cartilage but mid-line just above the sternal notch by palpation. Astutely, the NP abandons the oral ETT route and goes the nasopharyngel route hoping to have a straighter shot at the vocal cords. Saturations that had dropped into the 50's are no hovering in the low 80's to upper 70's. Temporarily satisfied, the child is moved to the NICU (neonatal intensive care unit). On arrival the saturations are noted to have dropped into the 60's but with agrressive bagging the saturations come up into the 70's.

Now, anesthesia arrives. They take a look and cannot see the vocal chords around the mass orally and do not want to dislodge the nasopharnygeal ETT already in place although clearly it is not in. There are bubbles from the mouth and if you close the mouth the saturations improve slightly. The NICU attending tries to intubate orally and cannot pass the tube, even with position change of the level of the head and back. Suctioning the mucous causes desaturations. There is the tiny ETT that the NP had placed initially which is really a nasopharyngeal airway, even an LMA if you will, at best. The anesthesiologist again tries to pass a small ETT (uncuffed) orally but fails. Now the airway is getting "bloody". The premie has destaurated into the 40's and the HR drops into the 60's as well. There is one IV access route. We are able to bag up to the 60's with a flicker of 70 on the SaO2 monitor with a return of the HR into the 130's. Again, the intermittent suctioning leads to bloody output mixed with mucous and greeted with desaturations. The pediatric surgeon has been called in but is 30 minutes away at least.

Anesthesia and NICU physicians try again and again the SaO2 drops. Only able to bag up into the low 50's to high 50's. The premie is bradycardiac and there is cardiac ectopy. The pediatric bronchoscope will not fit down the nasopharyngeal ETT.

The pediatric surgeon will not make it in time for this one and something must be done as they cannot keep the saturations up and the bradycardia becoming more persistent. There are about 25 various well-intentioned health-care practitioners gathered around now looking at you with that look: The look of, "Do something now . . . please!!!"

Now, what?

Remember this is a 32 week premie airway with a mass that goes from the tongue to the roof of the mouth and posterior to who knows where and the trachea is deviated. The chest x-ray which is really a baby-o-gram does not reveal much diagnostic information.

So, where would you go? (This happened last night.)

DM

[adal]

Needle Cric with Jet insuffilation (sp?) See if you can find a Boogie small enough to fit in the ETT if not try a wire guide. Seriously contemplate surgical trach do to poss damage of the cricoid rings and trachea and the ensuing edema. What a yucky call, NRP at its worst. How'd it turn out?

[cold1]

I would go to the little church and pray for all the good people doing their best to keep the baby alive and healthy.

No smartassedness intended, yall Docs get put in some tight places with heavy decisions to make. I dont envy you at those times.

God bless.

[Doc Dutch]

Yes. I pretty much realized that this was going to be a first in what was a rough spot. A first on something the size of my hand! But I figured it was even rougher for the little patient . . .

Well, we took an 18 gauge angiocath with a syringe of saline on the end. The saline in the syringe will let you know when you are in the trachea as you advance the needle and aspirate as you advance. Once you are in the airway, you get air bubbles. To be honest with you, it took several passes. Could not get the angiocath to pass over the needle. Would next time upsize to a 16 gauge or even 14 gauge if we could find one. After the last pass, got air, and were finally able to pass the catheter. Had an adaptor for the needle that would connect to a BVM. Bagged the child up to 90 percent. That bought the pediatric surgeon time to get into the NICU.

Another lesson is that whomever holds the needle in place, be careful not to kink the needle off once it is in. At one point we started to desaturate all of a sudden. Trouble shot quickly and found the catheter was being kinked by the person holding plastic angiocatheter. So, we sutured it in to secure it. That obviated the need for a second set of hands to hold the angiocatheter in place. Now the only person needed was the person bagging the premie which was fine considering the small area that we had to work. The NICU physician was the one bagging and hold complete control.

Next lesson, we left the nasopharyngeal airway in place even though we may not have needed it. We left it as a "just in case" as it got us that far. If the needle cric did fail, we could go back and see if it might work again. We removed it after the formal tracheostomy.

Another lesson, make sure that the OR staff (nurses and techs) are setting up the closest OR to the premie and that they have all the equipment needed (sizes of neonatal/pediatric trachs), so that while you are stabilizing the premie, they are busy setting up and getting ready. So, remember to call the OR. That seems like a no brainer, but in all of the tension . . .

Next lesson, this was an emergency but make sure you or someone makes the time to speak to the mom for procedures and keep her informed. Preferably before the procedure, but speak to the parents and let them know. Even for the premie's next procedure, the tracheostomy. Moms and dads must be informed at all times and keep them in the consent/decision making process. With all the people around, someone can do that. We managed it. But if you do not think ahead about it, in the rush to get the premie stabilized, parents can be forgotten. Once you remember, it can delay going to the OR and that can delay getting the needle cric converted over to a formal tracheostomy.

Finally, make sure that the needle cric gets converted over to a formal tracheostomy within 45 minutes. Why? Acidemia develops quickly as the needle cric is for oxygenation not for ventilation and CO2 builds up quickly. At one point the premie's pH was 6.7. It began to normalized post-op tracheostomy with ventilation and blowing of the CO2 and with better access through lines placed in the umbilicus for a larger resuscitation.

Phew! Where are the NICU team and premie now? The premie is alive but has a long road ahead of it and is not out of the woods by a long shot. If I hear any more, I will pass it along. When I left this morning the premie was alive.

Oh, one last thing. This also represents what I call, knowing when to "pull the trigger". "The trigger" is moving to provide the surgical airway. Once you decide, be decisive and move! It is often knowing when to push ahead despite others stating, "Hey, I want to try one more time." There comes a moment that you face the decision to provide a surgical airway. I will steal this phrase and say, when that time comes, "Just do it!" Pull the trigger and stick with your decision. I have never been disappointed when I have pulled it. I have been disappointed when I did not pull it soon enough (desaturations with cardiac ectopy or bradycardia with the airway physician begging that he almost has it in).

Time for a nap . . .

Thank you,

DM

[Red Flag 1]

Dutch,

Bad bad case!! Premies don't give you much time. Bradycardia in kiddies still makes the hair on my neck stand up! You are right about the nasal ETT as a nasal airway now and probably whistling in the graveyard at best. Nearly all neo-natal intubations are awake with no relaxants, the tongue on a neo-nate is very strong and the oral mass adds to your nightmare. With the left tracheal displacement, I have to wonder what else is going on that I can't see.

Two things I would probably try. First as adal suggested, needle cricothyrotomy using as large an IV intercath you are comfortable using; maybe an 18ga. Once in the airway pull the needle and leave the cath pointing caudad. I believe a 4.0 mm ET adapter will fit snugly into the hub of the intercath. Jet ventilate. This is not the total answer but can buy some time. I have done this in the ER with success on adults, CO2 buildup will become a problem but it can provide oxygenation in the short trem. In that small window of time, your surgeon will be nearer, and get Pedi Bronch stuff together. Mobilize the nearest surgeon to do a trach if needed.

Second would be for a more perm solution such as pedi bronch slide inside a pedi ETT. I think this is the best answer for ETT placement and a better look at the subglottic airway. Something has pushed the trachea to the left and it would be important to RO and subglottic airway mass!

Last resort, emergent trach.

Soft tissue studies of the neck to RO other masses. I'm willing to bet there may be another mass in the area of the glottis. I'd like to hear how this turned out. Bad Bad juju here.

RF 1

ps: It is possible to pull off a retrograde intubation using an epidural needle ( cricothyrotomy) with bevel oriented cephlad. Pass an epidural cath up into the oropharynx and grab it with a pair of clamps. Thread ETT over cath and down the cath through the cords. This is not easy and only a remote possibility. I doubt you will have enough room in the oropharynx given the mass your are dealing with. Kiddie may not have enough time for you to struggle through attempt; but it is possible.
rf

[Red Flag 1]

Dutch,

I type slow! Glad the outcome was positive for all!

RF 1

[Doc Dutch]

RF,

I do think next time (because there is always a next time or so it seems) I will go with the 16 or 14 gauge if I can find it readily. Bigger would have been better as it probably affords less kinking. I also agree with you that pointing the angiocatheter caudal and sliding the needle out once the angiocath is in or pushing in the catheter and removing the needle. I am not sure as to why for the first few attempts I could not pass the catheter over the needle and into the trachea. That was frustrating.

The retrograde intubation is a great idea. I have actually used this in another pediatric case (10 year old with c-spine and a t-spine fractures in a halo that lost his airway). The anesthesiologist and I did it together. Now that was "un-fun", but is really good to have in your arsenal of airway tools.

D-