Strategien zur Atemwegssicherung bei Neugeborenen

Zusammenfassung

Hintergrund

Das Atemwegsmanagement beim Kind, insbesondere bei Patienten mit einem schwierigen Atemweg, stellt nach wie vor eine große Herausforderung für jeden Anästhesisten, Pädiater und Notfallmediziner dar. Während der letzten Jahre wurden neue Hilfsmittel in den klinischen Alltag eingeführt.

Zielsetzung

Ziele waren die Darstellung aktueller Strategien zur Sicherung des Atemwegs bei Neugeborenen in Perinatalzentren der Level I und II sowie die Erhebung von Daten zum seltenen Ereignis der Koniotomie.

Material und Methoden

In der durchgeführten Studie handelt es sich um eine anonymisierte Online-Umfrage von intensivmedizinisch tätigen Ärzten in der Pädiatrie und Neonatologie.

Ergebnisse

Es schlossen 219 Teilnehmer den Fragebogen ab. Verfügbare Atemwegshilfen: 94,5 % (n = 207) Nase-Rachen-Tuben, 79,9 % (n = 175) Videolaryngoskop/Fiberoptik, 73,1 % (n = 160) Larynxmasken, 64,8 % (n = 142) Guedel-Tuben. Sechs Teilnehmer (2,7 %) koniotomierten selbstständig (⌀ 1,6 Kinder). Schulungen zur Koniotomie wurden in 98,6 % (n = 216) nicht durchgeführt. Eine Standardvorgehensweise (SOP) zum schwierigen Atemweg bei Neugeborenen besaßen 20,1 % (n = 44).

Schlussfolgerung

Internationale Vergleichsstudien geben Hinweise darauf, dass die Ausstattung deutscher Perinatalzentren im Hinblick auf das Equipment, wie Larynxmasken und Videolaryngoskope, überdurchschnittlich ist. SOP speziell für Neugeborene existieren kaum, obwohl die Notwendigkeit unbestreitbar ist. Die FONA-Methoden werden beim kleinen Säugling sehr selten angewendet. Es muss diskutiert werden, ob diese zeitkritische und unter Stress schwer durchzuführende Intervention durch Pädiater erfolgen sollte, da die praktische Erfahrung und damit Suffizienz dieser Technik schwer zu erlangen ist.

Abstract

Background

Airway management in children, especially in patients with a difficult airway, remains a major challenge for anesthesiologists, pediatricians, and emergency medicine physicians. In recent years new tools have been introduced into the clinical practice.

Objective

The aim was to present the current strategies for securing the airway in neonates in perinatal centers levels II and III in Germany, and to collect data on the rare event of coniotomy.

Material and methods

From 5 April 2021 to 15 June 2021, physicians practicing intensive care in pediatrics and neonatology at perinatal centers levels II and III in Germany were surveyed by means of an anonymized online questionnaire. The questionnaire was designed by the authors and verified by pretesting with the help of five pediatric specialists. Contact was made digitally via the e‑mail addresses provided on the websites of the respective centers. The survey was administered through the fee for service provider LimeSurvey©. The collected data were transferred to the IBM© statistical package for the social scientists (SPSS, version 28, IBM© Corporation, Armonk, NY, USA) and statistically analyzed. Pearsonʼs χ²-test was used to perform significance testing (significance level p = < 0.05). Only completed questionnaires were included in the analysis.

Results

A total of 219 participants completed the questionnaire. Available airway devices: 94.5% (n = 207) nasopharyngeal tubes, 79.9% (n = 175) video laryngoscope/fiber optic, 73.1% (n = 160) laryngeal masks, 64.8% (n = 142) oropharyngeal tube (Guedel). Of the participants 6 (2.7%) performed coniotomy (⌀ 1.6 children). Out of six cases five (83.3%) were resuscitation situations caused by complex anatomical malformations. Training of coniotomy was not provided in 98.6% (n = 216). A Standard Operating Procedure (SOP) for difficult airway in neonates was possessed by 20.1% (n = 44).

Conclusion

The comparison with international studies showed that the equipment of German perinatal centers is above average. The trend towards acquisition of a video laryngoscope and its importance in clinical routine could be confirmed by our data; however, the fact that 20% of the respondents did not have access to video laryngoscopy suggests that further acquisitions will have to be made here in the future. Front of neck access (FONA) methods remain a critically questioned component of neonatal difficult airway algorithms due to their rarity and the resulting lack of data. In summary of the recommendations of the British Association of Perinatal Medicine (BAPM) and the collected data on the theoretical and practical education of the FONA methods in Germany, the implementation of the FONA methods by pediatricians and neonatologists cannot be recommended. As most resuscitation situations were caused by complex anatomical malformations, the early detection of such malformations by means of high-resolution ultrasound seems to be of particular importance. With improvement of early detection, neonates with potentially unmanageable airway problems can be left on uteroplacental circulation for a prolonged period in order to perform necessary interventions, such as tracheostomy, bronchoscopy, or extracorporeal membrane oxygenation (ECMO) device known as the ex utero intrapartum treatment (EXIT) procedure.