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• Neonatal airway problems and the can't intubate can't ventilate scenario
  Janet M Rennie
  Published on: 23 January 2015

• Published on: 23 January 2015

  Neonatal airway problems and the can't intubate can't ventilate scenario

  • Janet M Rennie, Neonatologist
  • Other Contributors:
    • Giles S Kendall Caroline May

  To: The Editor, Archives of Disease in Childhood

  From: Dr Janet M Rennie Dr Giles S Kendall (NICU UCLH London)

  Dr Caroline May (NICU & NTS The Royal London Hospital, London)

  Comment on: Neonatal Airway Practices: Whitby T et al ADC Fetal and Neonatal Edition 2015:100: F92-93

  We read the letter from Whitby et al regarding neonatal airway practice with interest. We agree that neonat...

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  To: The Editor, Archives of Disease in Childhood

  From: Dr Janet M Rennie Dr Giles S Kendall (NICU UCLH London)

  Dr Caroline May (NICU & NTS The Royal London Hospital, London)

  Comment on: Neonatal Airway Practices: Whitby T et al ADC Fetal and Neonatal Edition 2015:100: F92-93

  We read the letter from Whitby et al regarding neonatal airway practice with interest. We agree that neonatal units need a "difficult airway" trolley, a guideline, and a "Can't Intubate, Can't ventilate" (CICV) algorithm. Like many units, we have thought hard about this over the last year and have reflected on our own clinical experiences.

  We suggest that the CICV algorithm proposed by Whitby et al is not suitable for translation to the newborn. There are several reasons why the newborn require a special approach; this is not "inequality". Most importantly, as pointed out by Johansen and colleagues, the cricothyroid space is simply too small to cannulate in a neonate and surgical cricothyrotomy is not an option (Johansen et al., 2012). Very few neonatal units would be able to obtain the services of an experienced paediatric ENT surgeon, or have the equipment for emergency tracheostomy, and this is only feasible in the larger term newborn even then and very few patients are unconscious at the time of acute airway compromise. Storz laryngoscopes (and other indirect laryngoscopes) are fantastic aids but it is impractical for such valuable equipment to form part of a "difficult airway" set kept in storage on a neonatal unit.

  We have had good success with the use of a bougie and the "railroad" technique, which is not mentioned at all in the algorithm proposed by Whitby et al. Laryngeal mask airways can certainly help, and the Igel devise looks promising. Further, a neonatal algorithm needs to recognise the possibility of a congenital problem such as Pierre Robin sequence, which requires recognition and special management (Abel et al., 2012) (Evans et al., 2011). Anticipation and planned securing of difficult airways is particularly important where congenital anomalies are known and rather disappointingly there is no mention of such planning in the Whitby algorithm. Such plans often need to be bespoke and carefully considered when facing such unique clinical situations and the baby's clinical condition may in fact be exacerbated by cricothyrotomy/tracheostomy eg. laryngeal web.

  In short, we agree that a CICV algorithm and a realistic "difficult airway" kit list are needed, but these need to be appropriate for the newborn and to be achievable by all units.

  Yours, etc..

  Reference List

  Abel, F., Bajaj, Y., Wyatt, M. & Wallis, C. (2012). The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience. Arch Dis Child 97, 331-4. Evans, K. N., Sie, K. C., Hopper, R. A., Glass, R. P., Hing, A. V. & Cunningham, M. L. (2011). Robin sequence: from diagnosis to development of an effective management plan. Pediatrics 127, 936-48. Johansen, L. C., Mupanemunda, R. H. & Danha, R. F. (2012). Managing the newborn infant with a difficult airway. Infant 8, 116-119.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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