Most paramedics (myself included) find intubating children with respiratory failure to be more than a little stressful, mostly because they are a cohort of patient with whom we have little experience. I suspect we also feel that the stakes are a little higher in a 10 month old versus the typical 87 year old cardiac arrest.
So here may be a way to at least stave off the need for intubation for a while. According to this paper from Pediatric Emergency Medicine the use of high flow nasal cannula in paediatric patients with respiratory insufficiency reduced the odds for intubation by 83%. Mortality and length of ICU stay remained unchanged, but anything that can avoid the occasional intubator having to reach for the blade of doom is a good thing in my mind.
I imagine that most paramedics are comfortable with the use of high flow nasal O2 as a means of apnoeic oxygenation whilst carrying out intubation. HFNC in the breathing patient probably works by the same couple of mechanisms: washing out deadspace to provide a reservoir of O2, and a slight positive pressure that improves alveolar recruitment and thus gas exchange. (In the apnoeic patient there will still be an uptake of approximately 250mls/min of O2 through diffusion, with about 50ml/min of CO2 produced, creating a gradient between the dead-space and the alveoli. Fill this gradient with O2 instead of room air and we have plenty of time to get a good view and place a tube)
If you choose to try this technique on children, bear in mind that it is not generally used with plain, ‘vanilla’ O2 that comes straight out of the tank; the gas is normally warmed and humidified and will be significantly more comfortable than the cold dry stuff we have on hand. As with most things involving children, I find that discretion may be the better part of valour and there is often a trade off between letting a child settle on it’s own and jumping in boots and all, potentially causing more distress.
If anyone has any experience with this in children let me know, I would love to know how well it worked in the field.
Wing, R., James, C., Maranda, L. S., & Armsby, C. C. Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency. Pediatr Emerg Care, 28(11), 1117-1123.