Dept. of Anaesthesiology & Intensive Care, 1st Faculty of Medicine, Charles University in Prague; General University Hospital, Prague, Czech Republic
The presented educational algorithm is a transparent, axial "cookbook" for solution of sudden laryngospasm in uncomplicated patient after surgery. Description of the situation and offered solutions are appropriate part of the algorithm together with the values of the monitored functions (SpO2, ECG, NIBP, RR), which emphasize the seriousness of the patient´s condition. Directness and simplicity and classification of individual steps in the whole clinical situation ensure easy comprehension and memorability of each phase of treatment. However it should be noted, that the incidence of laryngospasm is not strictly bound only to the submitted clinical situation. Generally, it is a protective and defensive mechanism that ensures closure airway against aspiration. So ultimately there are several situations where it is possible to occur. Its solution, however, remains the same or similar.
It is a well known medical fact, that the child should not be approached the same way as a shrunken adult would be. This is also true when speaking about the airway management. Specifics of paediatric airway securement are most noticeable in newborns and toddlers and they remain remarkable until the age of 6 to 7 years. Anatomical differences play the most important role. This applies, for example, to the difficulties with identification of the ligamentum conicum. The precise location of the thyroid cartilage is not easy to determine due the it’s shape and the morphology of children´s neck (that may be short and often impalpable). Other important distinction from adults is the size of the area, where the physician should perform BACT or coniotomy and the likelihood of traumatization of the wall of trachea and possibly of oesophagus. Apart from the structural dissimilarities, physiological and pathophysiological consequences, e.g. better tolerance of hypercapnia in children, should also be taken into account.1
This algorithm is well arranged in two branches of a predicted and an unpredicted difficult airway management situation based on everyday clinical practice.. To successfully go through this algorithm, it is absolutely essential to be familiar with the basics of the airway securement based in the VORTEX2 from the New Zeeland. Situations presented are rationally based and reflect the real-life medical practice. The physiological findings help to gain the overall understanding of the situations and the answers- both correct and incorrect- aim to familiarize the solver with the given issue. It is well understandable, that there are variations in preferred practices between different hospitals, based on the equipment available. For example, the paediatric ENT specialist with fibrooptics is not available in every hospital. It is important to note, that a catheter installation using the Seldinger technique and a connection to the mechanical ventilation, represents the best technique for surgical airway securement in newborns and toddlers. By using this approach we can avoid tracheal or oesophageal injury, which can happen during BACT or coniotomy. Characteristics of a given situation and specific needs of a patient should always be carefully considered.
It is surely an advantage to have the opportunity of working with a standardized procedure guidelines. Especially for the junior doctors this represents a recipe on how to act in stressful situation. The more experienced physicians can take these instructions as a basis and then adjust their actions according to specific patient´s needs.