Name: Guidelines for Elective Pediatric Fiberoptic Intubation (Video) | JoVE Journal
Uploaded: 2011-01-17T19:00:00.000+00:00
Duration: 11 min 19 s
Description: Learn a safe, reproducible technique for pediatric fiber optic nasal intubation while maintaining spontaneous ventilation. This method helps anesthesiologists and trainees manage challenging pediatric airways effectively.

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5 minutes

This work is funded by the department of anesthesiology at children's hospital of Michigan.

1. Equipment Preparation
<ol>
	<li>Med fusion pump for propofol infusion</li>
	<li>Place nasotracheal tubes under heating mattress</li>
	<li>Connect camera to scope and check orientation</li>
	<li>Three movements affect the view through the scope:
		<ol>
			<li>In and out.</li>
			<li>Rotation using a two-handed maneuver.</li>
			<li>Flexion and extension of the tip of the scope.</li>
		</ol>
	</li>
</ol>
2. Additional Equipment
<ol>
	<li>Fentanyl 0.5-1.0 mcg/kg </li>
	<li>12F red rubber suction catheter</li>
	<li>Glycopyrrolate 0.1-0.2 mg </li>
	<li>Metal insufflation hook</li>
	<li>Afrin nasal spray </li>
	<li>Lubricant</li>
	<li>Lidocaine 2% or 4% for spraying nares</li>
</ol>
3. Patient Preparation
<ol>
	<li>Perform mask induction maintaining spontaneous ventilation.</li>
	<li>Start IV and give fentanyl and glycopyrrolate IV.</li>
	<li>Give propofol bolus 1 mg/kg and begin propofol infusion 200 mcg/kg/min.</li>
	<li>Tape eyes before spraying Afrin to avoid dilation of pupils.</li>
	<li>Spray Afrin and lidocaine in both nares.</li>
	<li>Mask ventilate the patient to distribute Afrin and lidocaine distally.</li>
	<li>Pass red rubber catheter into both nares to check patency.</li>
	<li>Choose the more patent nostril for the fiberoptic scope.</li>
	<li>Keep the red rubber in the other nostril with tip in the hypopharynx for O2.</li>
	<li>Use insufflation hook to connect red rubber to the circuit and administer 2 L/min of O2 (don't insufflate high flows into the hypopharynx).</li>
</ol>
4. Actual Fiberoptic Intubation
<ol>
	<li>Take connector off the nasotracheal tube.</li>
	<li>Advance tube all the way up the lubricated fiberoptic scope.</li>
	<li>Clean fiberoptic tip with alcohol</li>
	<li>Put a slight curve on the end of the scope to follow the floor of the nose.</li>
	<li>Thread the fiberoptic to the larynx blindly.</li>
	<li>Look for any recognizable anatomic structures. FREEZE!</li>
	<li>Bring anatomic structures into the center of the field and keep them there.</li>
	<li>When approaching the vocal cords, give a bolus of propofol 1 mg/kg IV.</li>
	<li>Once through the cords, make a downward turn into the trachea.</li>
	<li>Follow tracheal rings to the level of the carina.</li>
	<li>You may require an additional propofol bolus of 1 mg/kg IV.</li>
	<li>Make sure the fiberoptic scope tip is in a neutral position.</li>
	<li>Thread the ETT. If the ETT gets hung up at the larynx, give a 360&deg; turn of the tube to spin it into the trachea.</li>
</ol>
5. Representative Results
This video shows an efficient technique for elective fiberoptic intubation in pediatric patients that is easily teachable to residents and fellows and reproducible. The main key is to maintain spontaneous ventilation at all times. Good equipment preparation before hand is also important.

<ol><li>Kinouchi, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Management+of+difficult+pediatric+airway%5BTitle%5D)+AND+%22Masui%22%5BJournal%5D)">Management of difficult pediatric airway.</a> Masui. 55, 24-32 (2006).</li>
<li>Chen, Y. L., Wu, K. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Airway+management+of+patients+with+craniofacial+abnormalities%3A+10-year+experience+at+a+teaching+hospital+in+Taiwan%5BTitle%5D)+AND+%22J+Chin+Med+Assoc%22%5BJournal%5D)">Airway management of patients with craniofacial abnormalities: 10-year experience at a teaching hospital in Taiwan.</a> J Chin Med Assoc. 72, 468-470 (2009).</li>
<li><a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Practice+guidelines+for+management+of+the+difficult+airway%3A+an+updated+report+by+the+American+Society+of+Anesthesiologists+Task+Force+on+Management+of+the+Difficult+Airway%5BTitle%5D)+AND+%22Anesthesiology%22%5BJournal%5D)">Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.</a> Anesthesiology. 98, 1269-1277 (2003).</li>
<li>Fiadjoe, J., Stricker, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pediatric+difficult+airway+management%3A+current+devices+and+techniques%5BTitle%5D)+AND+%22Anesthesiol+Clin%22%5BJournal%5D)">Pediatric difficult airway management: current devices and techniques.</a> Anesthesiol Clin. 27, 185-195 (2009).</li>
<li>Wheeler, M., Roth, A. G., Dsida, R. M., Rae, B., Seshadri, R., Sullivan, C. L., Heffner, C. L., Cote, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Teaching+residents+pediatric+fiberoptic+intubation+of+the+trachea%3A+traditional+fiberscope+with+an+eyepiece+versus+a+video-assisted+technique+using+a+fiberscope+with+an+integrated+camera%5BTitle%5D)+AND+%22Anesthesiology%22%5BJournal%5D)">Teaching residents pediatric fiberoptic intubation of the trachea: traditional fiberscope with an eyepiece versus a video-assisted technique using a fiberscope with an integrated camera.</a> Anesthesiology. 101, 842-846 (2004).</li>
<li>Roth, A. G., Wheeler, M., Stevenson, G. W., Hall, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+a+rigid+laryngoscope+with+the+ultrathin+fibreoptic+laryngoscope+for+tracheal+intubation+in+infants%5BTitle%5D)+AND+%22Can+J+Anaesth%22%5BJournal%5D)">Comparison of a rigid laryngoscope with the ultrathin fibreoptic laryngoscope for tracheal intubation in infants.</a> Can J Anaesth. 41, 1069-1073 (1994).</li>
<li>Ovassapian, A., Dykes, M. H., Golmon, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+training+programme+for+fibreoptic+nasotracheal+intubation.+Use+of+model+and+live+patients%5BTitle%5D)+AND+%22Anaesthesia%22%5BJournal%5D)">A training programme for fibreoptic nasotracheal intubation. Use of model and live patients.</a> Anaesthesia. 38, 795-798 (1983).</li>
<li>Stevenson, G. W., Roth, A. G., Wheeler, M., Hall, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Use+of+the+Olympus+LF-P+fibreoptic+laryngoscope+by+trainees+in+paediatric+anaesthesia%5BTitle%5D)+AND+%22Anaesthesia%22%5BJournal%5D)">Use of the Olympus LF-P fibreoptic laryngoscope by trainees in paediatric anaesthesia.</a> Anaesthesia. 51, (1996).</li>
<li>Taguchi, S., Kusunoki, S., Fukuda, H., Hamada, H., Kawamoto, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Difficult+tracheal+intubation+using+airway+scope+in+a+pediatric+patient+with+Hunter+syndrome%5BTitle%5D)+AND+%22Masui%22%5BJournal%5D)">Difficult tracheal intubation using airway scope in a pediatric patient with Hunter syndrome.</a> Masui. 58, 1278-1281 (2009).</li>
</ol>

No conflicts of interest declared.

Fiberoptic intubation in pediatric patients with difficult airway could be a challenging task1,2 and the presence of craniofacial dysmorphisms presents additional challenges to tracheal intubation3. It is more difficult to perform this procedure in pediatric patients than in adults mainly because of smaller airways in pediatric patients which make the manipulation of the fiberoptic more difficult since any small movement of the tip of the firberoptic scope runs the risk of touching the mucosa of the...

<table><tbody><tr><td>Med fusion pump for propofol infusion</td><td></td><td></td><td></td></tr><tr><td>Fentanyl 0.5-1.0 mcg/kg</td><td></td><td></td><td></td></tr><tr><td>12F red rubber suction catheter</td><td></td><td></td><td></td></tr><tr><td>Glycopyrrolate 0.1-0.2 mg</td><td></td><td></td><td></td></tr><tr><td>Metal insufflation hook</td><td></td><td></td><td></td></tr><tr><td>Afrin nasal spray</td><td></td><td></td><td></td></tr><tr><td>Lubricant</td><td></td><td></td><td></td></tr><tr><td>Lidocaine 2% or 4% for spraying nares</td><td></td><td></td><td></td></tr></tbody></table>

guidelines for elective pediatric fiberoptic intubation

Guidelines for Elective Pediatric Fiberoptic Intubation

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small ...

This video demonstrates a safe and reproducible technique for successful pediatric fiber optic nasal intubation. First, appropriate preoperative preparation and setup of the fiber optic scope will be demonstrated. Next patient preparation, including the induction of general anesthesia, will be shown.Finally, a technique for fiber optic intubation will be performed in which the fiber optic scope is inserted and guided through the airway and the endotracheal tube is placed in the trachea. This video provides an excellent format for teaching residents and trainees. Many challenges exist in the management of the pediatric airway for fiber optic intubation, including technical difficulty due to a smaller airway size than that of an adult.This smaller size requires more accuracy and precision, so the degree of difficulty is greater keeping the lens, and thus the view midline is more difficult and the procedure is sometimes less successful. A second major challenge is high oxygen consumption and faster oxygen desaturation in children. If ventilation is interrupted, generally individuals performing fiber optic intubation will struggle because of the limited time to perform the procedure in children.The technique shown in this video maintains spontaneous ventilation and oxygen delivery, thus allowing more time to perform the procedure. If technical difficulty is encountered, it is safe, efficient, easily teachable and reproducible. In this video, we will demonstrate several critical skills required for successful pediatric fiber optic intubation.First, we'll show proper equipment preparation. Then we'll demonstrate patient preparation, and finally, we'll demonstrate the procedure. This technique has evolved over years of experience and has been refined During active teaching of residents and fellows, many have been able to successfully complete the procedure on their first attempt.Patient safety is our utmost concern year after year. This technique has proven to be safe and valuable for our patients and trainees. Prior to beginning this procedure, prepare all of the equipment that will be needed.First, fill a syringe with propofol. Insert it into a syringe pump, and input the appropriate settings for bolus and continuous administration. This will be utilized for intravenous anesthetic administration.During the fiber optic intubation, place naot tracheal tubes under a heating mattress to warm and soften them. Connect the camera to the scope and check its orientation. Three movements will affect the view through the fiber optic scope, forward backward.Moving the scope deeper into the airway rotation in which the scope is moved from side to side and flexion. Extension of the tip of the scope in which the view is moved anterior and posterior, ensure that the following equipment is placed in the surgical area. Fentanyl, a 12 fro nail red rubber suction catheter glycopyrrolate, a metal insufflation hook, nasal decongestion spray lubricant, and two or 4%lidocaine for application of topical anesthesia in the nas.Begin this procedure with the patient on the operating table and the anesthesia and surgical teams present. Set up all standard monitors, including an EKG, blood pressure monitor, pulse oximeter, and temperature monitor. Typically, parents are present during this step.To prepare the patient for intubation, gently place a mask on the child's face to administer the anesthetic agents cevo, fluorine, nitrous oxide, and oxygen. Spontaneous ventilation should be maintained. Set up the syringe pump so that it is connected in line with the intravenous line.Attach the monitors including the EKG, blood pressure, pulse oximeter, and temperature monitors to the patient, and connect them to the anesthesia machine. Then insert an intravenous catheter into a vein of the child's arm. Next, insert the intravenous line to administer medications.Deliver an initial bolus of propofol of one milligram per kilogram. Then set the pump to deliver 250 micrograms per kilogram per minute of propofol in a controlled manner. Throughout the procedure, check the depth of anesthesia, verifying vital signs and lack of movement.The child will be completely asleep and unresponsive to communication because the child has less oxygen reserve, ensuring that the child is breathing spontaneously is critical. A background of cevo fluorine of 0.8 to 1%may be continued during the procedure via red rubber catheter to maintain a well anesthetized yet spontaneously ventilating patient anesthetic medications should be titrated to effect if during the procedure. Salivary secretions are copious glycopyrrolate, which reduces salivary, tracheal, bronchial, and pharyngeal secretions may be administered intravenously.Once the patient is fully anesthetized, the parents are asked to leave the room. Place clear plastic adhesive or paper tape over the child's eyes. The tape will prevent dilation of the pupils and will prevent secretions and solutions from getting in the eyes.During the procedure, place a piece of gauze over the tape, administer five to 10 drops of rine in each nare. Then using an aerosolize, introduce up to four milligrams per kilogram of lidocaine into each nare. The gauze over the eye tape will absorb any excess lidocaine or arin.Place a ventilation mask over the patient's nose and mouth to distribute the arine and lidocaine distally. Next, gently pass a red rubber catheter attached to suction tubing into each nostril in succession. To check the patent, see or openness of each nostril.Then lubricate the catheter with a glycerin steroid mixture. Leave the catheter in the less patent nostril. Ensure that the tip of the red rubber catheter is in the hypo pharynx of the less patent or less open nostril.Then use the insufflation hook to connect the catheter to the oxygen supply. Connect the breathing circuit to the catheter to administer two liters per minute of oxygen. Avoid insufflating high flow oxygen into the pharynx.If an oral airway is utilized, it is removed at this time. To perform the fiber optic intubation begin by taking the connector off the nasal tracheal tube. Advance the tube all the way up the lubricated fiber optic scope.Next, using alcohol swabs, clean the tip of the fiber optic scope one to two times using the lever on the instrument. Put a slight curve on the end of the scope to follow the floor of the nose. Insert the fiber optic scope into the patient's nose.Then thread the scope to the larynx blindly at the posterior pharynx. Once the scope is inserted, view the monitor to guide the scope into the trachea. Once the supraglottic is reached, pause and examine the monitor.For recognizable structures, the laryngeal structures should be identifiable. Also seen here are the adenoids base of the tongue, epiglottis, and vocal cords. Once the anatomic structures have been identified, bring the vocal cords into the center of the field and keep them there.Continue threading the fiber optic scope slowly and steadily. When approaching the vocal cords, give the patient a bolus of propofol. Once through the cords, use the lever of the scope to flex the tip downward to go over the bend in the airway.As soon as the vocal cords are passed, the tracheal rings will be visible steadily. Advance the scope until a bifurcation is seen. This bifurcation is the carina of the trachea.Here the trachea is divided into right and left bronchi. If the heart rate increases or the patient moves, administer an additional propofol bolus of one milligram per kilogram. When not going over corners and curves, make sure the fiber optic scope tip is in a neutral position.Once the trachea is reached, intubate the patient by threading the endotracheal tube already loaded on the scope and advance it until it reaches the trachea. If the endotracheal tube gets hung up at the larynx, give a 360 degree turn of the tube to gently ease it into the trachea. Then inflate the cuff on the endotracheal tube.Finally, while holding the endotracheal tube in position, slowly remove the scope in a neutral position. Check the patient for bilateral breath sounds. Then connect the endotracheal tube to the breathing circuit.Next, check the end tidal carbon dioxide monitor for evidence of carbon dioxide and secure the tube with tape. In this video, we have shown you a safe, quick reproducible technique for pediatric fiber optic nasal intubation that alleviates the time restrictions to completion. The technique shown in this video maintains spontaneous ventilation and oxygen delivery, thus allowing more time to perform the procedure if technical difficulty is encountered.This protocol provides an excellent format for teaching residents and trainees when used for teaching. The setup and protocol should be reviewed in detail before the procedure is attempted. Once mastered, this technique can provide reproducible success.It can be done in minutes if it is performed properly and allows extra time should difficulty be encountered. This often results in success in trainees who are attempting this for the first time While attempting this procedure. It's important to maintain spontaneous ventilation and adequate depth of anesthesia during the procedure.It's also important to diligently prepare the NES with the congested and lidocaine to minimize mucosal damage and topically anesthetize the airway. Children have increased airway protective reflexes, so the addition of the congested and lidocaine will help create a still patient ultimately leading to success.

guidelines-for-elective-pediatric-fiberoptic-intubation

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Learn a safe, reproducible technique for pediatric fiber optic nasal intubation while maintaining spontaneous ventilation. This method helps anesthesiologists and trainees manage challenging pediatric airways effectively.

Guidelines for Elective Pediatric Fiberoptic Intubation

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