Thursday, November 4, 2010

Pediatric airway nightmare

I'm trained in emergency medicine, and in my field we live in dread of the "difficult airway." Many lectures and articles and textbooks are devoted to preparing us for it. What's an airway? When patients have trouble moving air between the outside world and their lungs, they may need some sort of secure tube to be put there. After all, without an airway, you can't even get started breathing. ER docs put in these tubes all the time, and it generally goes okay, but there are certain people who for one reason or another are extremely hard to tube. This can include people with obese necks, trouble opening their mouths wide, cancers or swelling down there, and so on. These kinds of distorted anatomy can prevent us from seeing what we need to see in order to stick the tube down the trachea instead of just poking around blindly.

There are all kinds of ways to conquer the difficult airway. You can use a newfangled fiberoptic laryngoscope or an old-fashioned bougie, or you can throw in a handy LMA to buy time. You can do a needle cric and then transtracheal jet ventilation for a few minutes, or you can resort to a retrograde intubation using a Seldinger technique. You can even call for your surgical backup to come do a trach. And so on.

Last night in our clinic here in rural Indonesia our doctors faced the most difficult airway I have ever seen. Yet there was nothing about the patient herself that made it so hard. Let me explain.

A ten-year-old girl arrived, limp and gasping, draped in the arms of two people, though she only weighed about 20 kg. An IV snaked out of her arm. The history was of a couple of days of fever and worsening trouble breathing followed by a visit to a remote clinic, where they'd placed a line.

Almost from across the room, it was clear from the way she was breathing that this was an airway problem rather than a lung problem. So, some sort of infection blocking the airway. Oxygen levels low. Almost no lung sounds because so little air is getting in. Whatever the diagnosis, she needs an airway immediately. That simple thing might save her life and give her time to get over the infection. Without it she will die in minutes, right in front of us, this previously healthy little girl with a blocked airway.

Then followed long minutes of professional misery, wherein items one desperately needed were found to be absent, dirty, too big, or too small. I love our clinic, but we're not a hospital; we aren't equipped for intubations. (I'm looking forward to building a bigger facility here, with the tools we need to care for sicker patients. Plans for this are in the works.) Someone happened to have donated us a beautiful case of laryngoscope handles and blades, all nestled in red velvet; but the few tubes we had were the wrong size. We don't stock airway medications, though we had diazepam, which our doctors gave her in huge quantities to try to keep her from fighting the lifesaving tube. Let us breathe for you, baby. Normally, one uses paralytic drugs to keep (unconscious) patients still so we can carefully insert the tube and secure it safely. We had none such here. No stiffening rod to keep the tube from flopping limply; one of the nurses found some sort of wire in a back room. No bite blocks to fit her. As we scrabbled around, temporizing, trying this and that, we pushed air into her lungs, barely, with a bag-valve-mask assembly sized for an adult.

After a long saga, and as the bag-valve-mask method was beginning to fail, her O2 dropping despite optimum technique, our team got a tube in. In a way, it was easy. Her little epiglottis and vocal cords, though swollen and patchy, were perfectly visible, and the tube slid in without difficulty. In another way, it was a nightmare. Without the right drugs and equipment, these were bad intubating conditions, to say the least. She coughed and clawed and gasped. She regurgitated and bit and struggled. And the tube itself was precarious because far too small, and the end was half-buried inside her mouth. Though we carefully taped it to its connector, it pulled away on one occasion, whereupon she inhaled the tube and it had to be fished out of her throat before it disappeared down her trachea. That wouldn't have happened with a tube that fit.

Still, she had an airway. That was what she needed. She calmed down. Her oxygen levels rapidly normalized, her lungs finally whooshed as lungs should, her speeding heart slowed a bit.

Now she needed a ventilator machine, complete sedation and more thorough diagnostics. Possibly she would need an abscess drained. We aren't equipped for any of that here. But it seemed worth it to try to obtain those things for this child, who after all had what amounts to a simple plumbing problem.

To say "We then transferred her to the ICU" would be technically accurate, but it would be inadequate to describe our difficulty in so doing (for example, a doctor held that faulty connector pinched between his fingers the whole way), as well as our disappointment on arrival. I am told that "ICU," which is hours away by ambulance, had no working suction, no ventilator machines, and evidently no airway management capability, as they removed her tube and did not replace it. Her oxygen levels began to drop again, and that was that. I hope the steroids and antibiotics we gave her will work in time. But I doubt she will survive this illness. Maybe all that diazepam means she's not suffering.

And so, my ER colleagues, I submit to you that the most difficult airway is not that of the large-tongued or the cancerous, not that of the obese or the swollen. It is the airway you try to secure without the tools you need.

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