Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

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Summary

The recent and ongoing COVID-19 pandemic has caused significant apprehension and strain on health care workers (HCWs) and the system. This is unsurprisingly exaggerated by the lack of evidence available to clinicians. This consensus guideline created by the Pediatric Difficult Intubation Collaborative (PeDI-C), provides practical and sensible recommendations on the anaesthetic management of the COVID-19 known or suspected paediatric patient.

They used interesting and progressive methodology indicative of the current social restrictions including a WhatsApp forum hosted webinar and zoom conferencing. From this, the international collective of airway experts, formed several themes with recommendations. These are summarised below.

 

Training

• Context sensitive simulation recommended i.e. train in your role.

 

Protecting Clinicians

• Re assigning HCWs who are at high risk of morbidity and mortality from COVID-19 to low risk areas such as telehealth.
• The health and safety of HCWs should take priority over insufficient personal protective equipment (PPE).
• Children infected with COVID-19 can asymptomatically shed the virus. Thus, PPE should be worn for aerosol-generating medical procedures (AGMPs) in all children in areas with high community spread.
• A PPE coach should be available to ensure correct donning and doffing of PPE.

 

Cognitive Aids

• There is a need for easily readable and comprehensible clinical care and workflow aids that should be printed, laminated, and mounted in locations where such care is administered.

 

Case Preparation

• Preparation is essential to prevent contamination of workstations and other areas. Suggestions such as covering touch screens with plastic and leaving non-essential items outside the room where AGMPs are to occur.

 

Premedication

• Advised to give to allow pre-induction intravenous (IV) access or to perform a gas induction with less aerosolization.
• Nasal route was thought best avoided.

 

 

AGMPs

• Recommend IV induction. However, if a child is struggling it may increase respiratory droplet spread.
• Rapid sequence induction (RSI) or modified RSI recommended to minimise aerosolization.
• If gas induction, low flow rates, a good seal and avoidance of positive pressure ventilation. Also, a transparent plastic barrier around the anaesthesia elbow to minimize extensive contamination of the room.
• Parental presence was not recommended, due to PPE shortages and more exposure of HCWs to COVID-19.

Airway Device Placement Recommendations:

• Cuffed ETT
• Video laryngoscope
• Most experienced intubator
• Inline suctioning
• Viral filter between the breathing circuit and patient
• A 2^nd viral filter between the end of the expiratory limb and anaesthetic machine
• Negative pressure room
• Avoidance of procedures that bring the HCWs face close to the patient e.g. auscultation
• LMA could be considered if well seated.

 

Maintenance of Anaesthesia

• Wear PPE throughout the procedure in case of accidental disconnection.
• A transparent barrier over the patient’s airway and head to trap aerosolized virus.

 

Emergence and Extubation

• Deep extubation is recommended.
• Use of a transparent barrier is suggested to contain aerosolized virus.
• Recovery in theatre to limit transfer and exposure of HCWs.
• If the patient is from intensive care, consider extubation being done there.

 

Infrastructure

• Negative pressure rooms for AGMPs are recommended for all proven or suspected COVID-19 patients.
• If not available, high-efficiency particulate air (HEPA) filters that sufficiently filter the theatres square footage.

 

Difficult Airways

• Preparation of the team and equipment prior.
• The most experienced with the selected airway device should perform intubation.
• Ranked approaches:
  1. Video laryngoscopy
  2. Fibreoptic through a supraglottic airway device
  3. Video laryngoscopy and fibreoptic bronchoscopy
  4. Fibreoptic intubation (oral preferred over nasal)
• If hypoxia ensues, intermittent 2 -hand mask ventilation with good seals and low tidal volumes suggested.
• Consider paralysing at induction with sugammadex readily available for reversal if needed.

 

The guideline is also complemented by explanatory pictures and links to videos.

Take home message

Much of the advice given in this article appears common sense. However, without prior consideration combined with the high stress situation clinicians may face when managing a known or suspected COVID-19 patient, it would appear easy to forgo simple measures and to potentially cause serious morbidity or mortality to their patient, themselves or the surrounding team. Thus, this formulates an easily digestible guideline which has many transferrable recommendations that could be used in the adult population.

 

Reviewed by Dr Sorcha Evans