What is the recommended approach for procedural sedation in pediatric (peds) patients with laryngomalacia in the emergency department (ED)?

Procedural Sedation in Pediatric Patients with Laryngomalacia in the ED

For pediatric patients with laryngomalacia requiring procedural sedation in the emergency department, ketamine (without midazolam) is the preferred agent due to its preservation of airway reflexes and excellent safety profile, while avoiding medications that may cause respiratory depression.

Understanding Laryngomalacia and Its Implications

Laryngomalacia is the most common congenital malformation of the larynx characterized by:

• Collapse of supraglottic structures during inspiration
• Inspiratory stridor that worsens with agitation, crying, or supine positioning
• Potential for airway compromise, especially in severe cases 1

This condition creates special considerations for procedural sedation due to the already compromised upper airway, making medication selection critical to avoid respiratory complications.

Sedation Agent Selection for Laryngomalacia

Recommended First-Line Agent: Ketamine

Ketamine is strongly preferred for several key reasons:

• Preserves respiratory drive and protective airway reflexes 2
• Maintains or increases muscle tone in the pharyngeal structures
• Provides both sedation and analgesia
• Has an excellent safety profile with very low incidence of laryngospasm (0.9-1.4%) 2
• Does not require IV access if given intramuscularly

Dosing recommendations:

• IV: 1-2 mg/kg initial dose, with 0.5-1 mg/kg incremental doses as needed
• IM: 4-5 mg/kg (if IV access not available) 2

Agents to Avoid or Use with Extreme Caution

1. Benzodiazepines (particularly midazolam):

   • Can cause respiratory depression and decreased muscle tone
   • May exacerbate airway collapse in laryngomalacia
   • Note: Adding midazolam to ketamine does not decrease emergence reactions but increases risk of respiratory events 2

2. Propofol:

   • Causes significant respiratory depression and loss of airway tone
   • Higher risk in patients with compromised airways
   • If used, should be at reduced doses and with extreme caution

3. Opioids:

   • Cause respiratory depression
   • Should be avoided or used at minimal doses if analgesia is required

Monitoring and Safety Considerations

Given the increased risk in laryngomalacia patients:

• Pre-procedure assessment:

  • Evaluate severity of laryngomalacia
  • Assess for signs of upper respiratory infection (increases laryngospasm risk 3.94 times) 3
  • Determine ASA status (higher status correlates with increased complications) 3

• Required monitoring:

  • Continuous pulse oximetry
  • End-tidal CO2 monitoring (capnography)
  • Regular blood pressure measurements
  • Respiratory rate and effort assessment 4

• Equipment preparation:

  • Position for optimal airway management
  • Have appropriate-sized airway equipment immediately available
  • Prepare reversal agents if applicable
  • Ensure suction is readily available

Procedural Approach

1. Pre-sedation:

   • Position patient with slight elevation of the head (avoid supine flat positioning)
   • Administer supplemental oxygen
   • Ensure IV access when possible (though IM ketamine is an option)

2. Sedation administration:

   • Use ketamine as primary agent
   • Titrate to effect using smaller incremental doses
   • Avoid deep sedation if possible; aim for moderate sedation

3. Recovery:

   • Continue monitoring until fully recovered
   • Maintain head elevation during recovery
   • Observe for at least 30 minutes after final medication administration 2

Special Considerations

• For brief procedures: Consider intranasal or atomized medications if appropriate for the procedure 2
• For longer procedures: Be aware that longer sedation times correlate with increased complication rates 5
• For painful procedures: Use local anesthetics when possible to minimize need for systemic analgesics

Potential Complications and Management

• Laryngospasm: Most serious concern; have equipment for immediate management ready
• Oxygen desaturation: More common in patients with laryngomalacia; provide supplemental oxygen
• Apnea: Less common with ketamine but still possible; be prepared for airway support

Remember that pediatric patients with laryngomalacia are at higher risk for airway complications during sedation, and medication selection should prioritize agents that maintain airway patency and respiratory drive, with ketamine being the safest option in most cases.