Slaying Different Dragons – A Quest

A little while ago Dr Andrew Weatherall was asked to give a talk on the difficult paediatric airway. The audience was a variety of emergency medicine doctors, nursing staff and allied health staff. He decided to try something dopey – audience participation. It wasn’t recorded so here’s the written version where the aim is to capture how it went down. 

The aim of this thing is very simple: to cover all there could possibly be to know about the difficult paediatric airway in a very short bit. Or not, of course. If it was that easy to cover a lot of the subspecialty of paediatric anaesthesia wouldn’t really be a thing.

What can be done in a little short bit is a revisit of things most of us know because sometimes the important thing is to take up some time and space to look at things slightly differently.

So for this little bit on airways I’m going to ask you to go on a quest. A quest to conquer the airway version of a dragon – rare and a bit scary. I guess this makes me the Quest Master (look, I’d go with Dungeon Master but there would probably be some sort of copyright issue there, I don’t know).

Of course any quest needs heroes which means we need to introduce some characters. [Sidenote here: people say you should never with kids or animals but for a moment when asking for volunteers to come out the front I was starting to wonder why they hadn’t include educational meeting crowds.]

The Characters

Each character hopefully brings some special skills to the table. They are, in no particular order:

The Engineer – who is good with their hands and getting practical stuff done.

The Master Toolsmith – skilled in the acquisition and selection of things that are required.

The Philosopher – the philosopher is particularly good at thinking and thinking about thinking but also has an active not entirely amateur interest in pharmaceuticals it turns out.

The Butcher – good with a knife and OK with the sight of blood.

Oh, and there will be one other character who will only appear as an evil, disembodied laugh in your consciousness. But more of the later.

And Now The Quest …

The local health facility in The Village, which actually services almost all the kids needing serious care locally, is going through challenging times. Forced underground by extensive renovation and rebuilding works to “facilitate better health experiences” and left short-staffed by unanticipated entirely predictable surges in demand, it draws on people who had wholly different lives before they started working in the emergency department. An engineer, a master of tools, a philosopher and a butcher.

While on a  break and bonding over war stories and some non-alcoholic mead the heroes are approached by the triage nurse. A 2-year-old patient with a background of trisomy 21 has arrived and they’ve ingested caustic material which probably had nothing to do with the cafeteria. The triage nurse asks the team to assess and manage the patient, making sure to utter trigger words relevant to the scenario,

“He’s heading for a tube.”

The First Question

The first question I had as QuestMasterTM was “which airway in the emergency department should we think of as difficult?”

The group in the not particularly hot seats came up with some excellent suggestions incorporating issues like underlying pathology, pre-existing syndromes, the nature of the acute illness and the physical examination of the patient.

The version of the answer I’d prepared had one key point: we should assume every airway in the emergency department is difficult. Not that long ago Long, Sabato and Babl published work looking at the intubations across a year in a busy (and I’m sure, very good) paediatric emergency department. With all their 82,000 presentations per year they needed to perform a total of 71 intubations. There were adverse events in 39%. The first pass intubation success rate was 78% and their first pass success without desaturation or hypotension was 49%.

Kids’ airways are tough for experienced kids emergency practitioners.

That said it is worth taking the time to take note of particular things that might make it tough. Obviously the respiratory and cardiovascular status are important considerations as are any underlying conditions known to be associated with difficult airway management (syndromes and neuromuscular things are a good starting point) because most kids’ difficult airways are predictably difficult, not a complete shock.

And slowing down to make a point of examining the airway can help. Even in kids I still quite like the LEMON mnemonic (for Look, Evaluate, Mouth Opening, Obstructions (like swelling, saliva, blood, fractures, foreign bodies or masses etc) and Neck (movement and anatomy) as long as you take note of the fact that Evaluation with things like thyromental distance isn’t so well validated or easy to remember in kids (but size of jaw, position of thyroid/larynx and the like are worth having a look at) and mouth opening can be hard to assess (but is more useful than Mallampati which should formally include tongue protrusion).

Of course, with a short period of time we didn’t go too much into all the bits before choosing whether or not you would need to intubate. It was that sort of session, the triage nurse was right.

Let’s Pause Time

Now in any good quest there is usually scope for the use of special items. For this quest the first special item, represented in the form of a large clock, the team was allowed to deploy the “FirstNet Magical Device of Time Relativity” capable of making time speed up, slow down or become entirely unhinged from reality in the manner of all good computer systems.

So our heroes took the step (after some very intense hinting) of suspending time so they could go and check the old books, in particular “The Book of Ye Olde Knowledge and Understandings” to make sure that some simple things about the paediatric airway and its management were understood equally by all.

So we wanted to double check that the things we all knew about blades, rings and cuffs was up to date.

Except the problem with old books is they need updating, and sometimes the best bits are the helpful scrawls in the margins where people have provided newer info.


What do the marginalia have to say?

Well we now know that it’s not so vital whether or not you choose a straight laryngoscope blade or a curved blade in kids, it’s about using the right technique. We know that the cricoid ring probably isn’t the narrowest part of the paediatric airway. We know that, used appropriately, a cuffed endotracheal tube is usually a perfectly reasonable option. (And because this site has covered that stuff before, you can go here for more details.)

We still had some time thanks to the FirstNet Magical Device of Time Relativity so we took the opportunity to drop by the armoury to gather the tools we’d need for the job, a task undertaken by the Master Toolsmith.

The Armoury

Again there was a lot of good discussion about what to choose and how to think about what you’d need. Broadly the Master Toolsmith made sure there was the requisite equipment to undertake pre-oxygenation and basic airway management, the necessary equipment for plan A (being intubation with a laryngoscope (video or direct) and an appropriate endotracheal tube and one size down), suction, those things necessary to secure the airway so the applied option didn’t fall out, the necessary drugs for the intubation and after intubation care and the things you’d want for the other potential plans (supraglottic airways and surgical options).

The Set-Up

With kit in hand the heroes also moved straight onto talking about how they’d set up to get it done. In brief there are probably 4 things to think through:

  • The space – think about the layout of your working space. How much access do you have around the treatment area? Are the things you need logically laid outing easy to get to? Are the things you need right now closest to you? Is there anything you can optimise?
  • The bed – I mention this one specifically because so often people seem to be stuck on the idea that the bed must be absolutely flat for airway instrumentation. Why? Have a really good think about whether having the patient sitting up at least a little might be a better option for functional residual capacity and respiratory management.
  • The kit – you’ve chosen it but have you double checked it worked and briefed what you’ll do.
  • The people – the agreement of most seemed to be that you’d probably want four people ideally. One to manage the drugs, one for doing the technical stuff, one as the assistant and one keeping an eye on the big picture. Of course if you’ve trained for it you can do it with less but we’re talking about optimising things where we’ve assumed a difficult airway.

The philosopher had the very good impulse to summon expert help as part of the team. And that was indeed an excellent instinct, but this was the sort of quest where we wanted to get them to other branches in the choose-your-own adventure. So much as they tried the “Charmed Summoning Rock of the Switch” I’d provided, the response seemed to be slow right now.

Oh, and one quick note on the drugs. Both the talk and post version are waaaay too brief to go through all the ins and outs of choosing induction agents but perhaps the crucial bit is to get comfortable with a couple of agents and be familiar both with the advantages of said drug and the things that aren’t so desirable that can happen with that potion.


Now this might be a fake medievalist quest but the good people of this village know the benefit of a few moments of quiet meditation. And that’s what preoxygenation is good for. The key elements of pre oxygenation appear to be successful delivery of high concentrations and time.

It’s also important to note that applying nasal prongs to sit under the mask isn’t necessarily going to help preoxygenation. It might extend the time to desaturation once the mask is off (and the evidence for that isn’t super overwhelming on my reading, particularly in kids) but it doesn’t seem to enhance the expired oxygen levels after a few minutes of preoxygenation. This is probably because in adding those prongs you break the seal for a mask which allows entrainment of 21% oxygen and violates the “deliver high oxygen concentrations” bit.

The mainstay of preoxygenation should still be a mask that fits well with a circuit delivering high-flow oxygen and time (think at least 3 minutes). The basics done superbly.

The 3 minutes of zen time also lets you talk through what you’ll do and take a few deep breaths yourself.

Let’s Roll the Dice

As for any good quest, we need something to help us know if the chosen path leads to success or not. Which is where these come in …



The Engineer, being the person to get practical things done picked up the 20-sided dice and rolled an 11. Which happily was a very good number to roll (although anything over 3 would have done the job because more often than not things will go fine). The preoxygenation was brilliant, the medications were well chosen, the laryngoscopy was not at all an issue and the endotracheal tube was placed without any fuss at all.

Success! \o/

Of course at that moment, our fifth player enters in the form of an ominous and evil laugh…

This is of course The Evil Necromancer of the Executive Suite who, armed only with a clipboard and an email account, is capable of inflicting multiple contradictory realities on hardworking clinicians at any moment.

So just as our heroes have triumphed, they find themselves back at the point of preoxygenation, ready to roll again.

Roll 2

The dodecahedron is rolled this time and the number 9 comes up. This was a very disappointing number to roll. The attempt at intubation is unsuccessful.

So at this point, what things are going through the mind (apart from ‘which idiot who recently watched “Stranger Things” based an airway talk on a Dungeons and Dragons game…)?

Well most departments will have something like the following on the wall and will have trained to work through it…


Now this is a good algorithm with lots of sensible things on it. It’s also one that might be hard to work through in the heat of battle with an airway dragon. It’s one to have tried to digest beforehand.

I checked with The Philosopher and we both agreed that at times of stress it’s pretty useful to be able to reduce our thinking to simple things. Things that we can visualise easily and know what they mean.

I personally quite like the simple mental overlay offered by the Vortex Approach.


It’s just a good reminder that there are three things to try optimising and stresses the need to keep moving (appropriately) and with caution.

All the detail behind it are probably beyond inclusion here so maybe go and have a look at the site and see what you think.

Whichever mental pathway they used to get there, The Engineer asked the Master Toolsmith for a supraglottic airway and they reached a point of safety with successful oxygenation. \o/

And the Charmed Summoning Rock of the Switch I’d provided earlier finally summoned both anaesthetics and ENT from their highly important coffee sojourns and a plan was made to proceed to theatre in a controlled fashion.


But then the evil laugh of The Evil Necromancer of the Executive Suite rang out again.

The team are back at the point where preoxygenation was just ending…

The Third, Fourth and Fifth Rolls…

This time all the rolls for mask, supraglottic airway and endotracheal tube came up with the wrong number. Look, it doesn’t matter which wrong number they were all just the wrong number.

The time came for a player who had offered many words but not many actions to step forward. It was time for The Butcher.

At this point in the artificial scenario it was time to chat through different front of neck access techniques. The most important things to note about front of neck access in kids would be:

  • It is extremely rare to need this, and with the standard approaches and early summoning rocks that work should be avoidable almost every time.
  • The suggested techniques in different age groups are based on consensus and that consensus is invariably hard for people to arrive at. Most people seem to suggest cannula cricothyroidotomy in the under 8s, but I’ve seen some paediatric anaesthetists publish opinions that those kids should definitely have a scalpel technique deployed. Either way the anatomy can be hard to define and there are those who suggest abandoning all pretext of finding the cricothyroid membrane and just aim for trachea. Access to the area can also be difficult just because it’s a tight little spot. Any which way in smaller kids the trachea is very pliable and it is very easy to produce posterior tracheal wall injury or even puncture. There are no good options here.
  • The best bet is therefore not getting to that point.

The best review of recent times on this topic is by that punter Sabato again (and was discussed here on this website).

As a general point on this if you are looking at front of neck access there are a few practice points worth contemplating:

  • It’s worth continuing to attempt to provide oxygen from the top end.
  • Prepare early – briefing it before everything is a good start and after that first challenging attempt ideally someone should be starting to get ready with just that job in mind.
  • That person has to mentally focus only on managing access from the neck.
  • After that it’s important to slow things down a little rather than try to be super fast, talk out loud through what you’re doing and involve the team. You might as well share that stress.

Amazingly in this case the Butcher deploys a cannula with excellent technique, hooks up to an appropriate device for provision of oxygen without jetting ginormous pressures and achieves oxygenation just as those summoned by that pesky magic rock turn up.

Success! \o/

And this time The Evil Necromancer must be on a conference call because there is only silence.


The patient and their airway have been successfully managed. The team will retell their story, first to the other workers who will take over care of the patient and then in the parchment version of the patient record so others may hear tales of their noble quest.

They will recall that all paediatric airways could be considered difficult. They will write new books in which the useful things in the marginalia are actually just the things written in the books. They will teach people about knowing their equipment and set-up, briefing a well-drilled team, optimising their chances with each technique and the great joy to be found within the meditation of pre-oxygenation. They will talk about achieving clarity through simpler thinking at moments of stress.

And at the end of the shift they might just go and find some mead that isn’t labelled non-alcoholic. And even plan their next encounter with a different kind of dragon.



To any attendees from the day who stumble across this I hope this is a pretty fair representation of the session. Thanks to a particularly interesting overnight bit of work I got to this on two hours sleep and there’s a chance my recollection is fogged in a little by that. Please correct me if you spot anything.

The paper by Long, Sabato and Baby on the experience of intubation at RCH ED in Melbourne is here:

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia 2014;24:1204-11. doi: 10.1111/pan.12490

You can find the post that covers myths in paeds airways here.

A colleague from CareFlight, Dr Chris Groombridge, did a nifty little study in pre oxygenation and the best expired oxygen achieved here:

Groombridge C, Chin CW, Hanrahan B, Holdgate A. Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. 2016;23:342-6. 

And there’s a similar one showing that having those high-flow nasal prongs probably only makes pre-oxygenation better where you don’t have a seal with the mask.

Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68:174-80.

Interested in the Vortex Approach and didn’t click up there above? Try out here.

Here’s the Sabato and Long review on CICO in kids:

Sabato SC, Long E. An institutional approach to the management of the ‘Can’t Intubate, Can’t Oxygenate’ emergency in children. Pediatr Anesth. 2016;26:784-93.

And here’s the paper on the development of difficult paeds airway guidelines:

Black AE, Flynn PER, Smith HL, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Pediatr Anesth. 2015;25:346-62.

Did you get all the way to the end here? Well good on you and have a reward. I know you’ve seen it already but it’s epic so let’s go with something that’s a little like a dragon. Enjoy this baby iguana escaping snakes over and over and use it as a metaphor for something in your daily life.




One response to “Slaying Different Dragons – A Quest

  1. Pingback: Slaying Different Dragons – A Quest — Songs or Stories | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds·

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