DÄ internationalArchive17/2010Use Familiar Material
LNSLNS The authors are quite right to state that, “Securing the airway [...] requires special knowledge and manual skills ”. What is difficult to understand is the assertion that “orotracheal intubation […] is to be preferred in emergencies”. The primary issue is really not intubation, but oxygenation.

If a child has a difficult airway, or if ventilation with a face mask turns out to be difficult or impossible, this is mostly due to errors in the positioning of the head or mask, or of the patient’s body. If positioning, the Esmarch maneuver, lifting the chin or Güdel’s tubes are all unsuccessful, the anesthesia must be immediately deepened and an alternative airway must be selected. As many physicians have had extensive experience with the laryngeal mask, the laryngeal mask should be the first choice in children.

Most emergency physicians are not pediatricians and are used to curved McIntosh’s spatulas. To avoid mistakes, they should use familiar material, particularly under stress or in emergencies. If Miller’s spatula fails to lift the epiglottis, intubation is impossible.

The cricoid cartilage (not “below the cricoid cartilage”) is the physiological bottleneck in a child’s respiratory tract and must be passed atraumatically. If there is damage, this may have happened because the selected tube is too wide. If intubation is necessary, a small but cuffed tube must be regarded as the gold standard. The resistance of the respiratory tract is irrelevant in ventilation. And why should an excessively small tube cause hyperexpansion of the lung?

Even under routine conditions, intubation of children requires enormous experience and regular training. Safeguarding a child’s respiratory tract is an enormous challenge for many emergency physicians. Although endotracheal intubation is established as the gold standard within the hospital, it can hardly be used preclinically. In this situation the supraglottic airway must be used and will guarantee a safe airway. The physician performing the intubation must master this flawlessly.
DOI: 10.3238/arztebl.2010.0304a

Prof. Dr. med. Jochen Strauß
Dr. med. Karin Becke
Wissenschaftlicher Arbeitskreis Kinderanästhesie der DGAI
HELIOS-Klinikum Berlin Buch
Klinik für Anästhesie, Perioperative Medizin und Schmerztherapie
Schwanebecker Chaussee 50
13125 Berlin, Germany
jochen.strauss@helios-kliniken.de
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Meyburg J, Bernhard M, Hoffmann GF, Motsch J: Principles of pedi-atric emergency care. [Grundlagen für die Behandlung von Notfällen im Kindesalter]. Dtsch Arztebl Int 2009; 106: 739–48. VOLLTEXT
1. Hoehne C, Haack M, Machotta A, Kaisers U: Atemwegsmanagement in der Kinderanästhesie, Anaesthesist 2006; 55: 809–20.
2. Holzki J: Laryngeal damage from tracheal intubation. Paediatric Anaesthesia 1997; 7: 435–7. MEDLINE
3. Müller-Lobeck L, Birnbaum J, Spies C: Kindernotfälle – Allgemeine Behandlungsstrategien, Anästhesiol Intensivmed Notfallmed Schmerzther 2009; (44) 6: 422–7. MEDLINE
4. Meyburg J, Bernhard M, Hoffmann GF, Motsch J: Principles of pedi-atric emergency care. [Grundlagen für die Behandlung von Notfällen im Kindesalter]. Dtsch Arztebl Int 2009; 106: 739–48. VOLLTEXT