4. Objectives
By the end of this workshop, the learner will:
‐ List 5 anatomical differences between a pediatric and
adult airway
‐ Describe in your own words at least 3 physiologic
factors that make pediatric patients more susceptible to
hypoxemia
‐ Discuss initial airway maneuvers using case-based
examples
Pediatrics
Page 4
xxx00.#####.ppt 11/21/13 09:43 PM
5. Children are NOT small adults!!!
•Major differences between pediatric and adult
airway are:
‐ Size
‐ Shape
‐ Position
•Pediatric airway similar to adult at approx. 8-14
years of age
Pediatrics
Page 5
xxx00.#####.ppt 11/21/13 09:43 PM
9. Physiologic Differences
•Lower %age of slow twitch muscle fibers
•Preferentially nose-breathers
•Compliant chest wall
•Ribs in a horizontal position
•Flatter diaphragm
•Higher oxygen consumption
•Higher MV:FRC
Pediatrics
Page 9
xxx00.#####.ppt 11/21/13 09:43 PM
10. Physiologic Differences
•Lower %age of slow twitch muscle fibers
•Preferentially nose-breathers
•Compliant chest wall
•Ribs in a horizontal position
•Flatter diaphragm
•Higher oxygen consumption
•Higher MV:FRC
Pediatrics
Page 10
xxx00.#####.ppt 11/21/13 09:43 PM
11. Initial Maneuvers to Clear Airway
•10 mos. old with mild-to-moderate laryngotracheitis
(i.e. viral croup). Child is sitting on mother’s lap
and found to have intermittent stridor at rest,
normal mentation, no agitation, mild retractions,
some decreased air entry B/L and no cyanosis
(SpO2 98% on RA).
‐ Suction as needed
‐ Oxygen as needed
‐ Allow to assume position of comfort
Pediatrics
Page 11
xxx00.#####.ppt 11/21/13 09:43 PM
12. Initial Maneuvers to Clear Airway
•3 year old with a retropharyngeal abscess exhibits
dysphagia, odynophagia and some drooling. Also
noticed is dysphonia, stertor, mild subcostal
retractions. Child has normal mentation, no
agitation, and no cyanosis (SpO2 95% on RA).
‐ Suction as needed
‐ Oxygen as needed
‐ Allow to assume position of comfort
Pediatrics
Page 12
xxx00.#####.ppt 11/21/13 09:43 PM
13. Initial Maneuvers to Clear Airway
•14 year old with meningitis who has a gradual
change in mental status (from GCS of 13 to 9) over
the course of the day. Exam reveals stertor, mildmoderate supra-sternal retractions during
inspiration and no cyanosis (SpO2 93% on RA).
‐ Suction as needed
‐ Oxygen as needed
‐ Jaw thrust
‐ Head tilt-chin lift
Pediatrics
Page 13
xxx00.#####.ppt 11/21/13 09:43 PM
18. Points of Emphasis: BVM Ventilation
From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)
Pediatrics
Page 18
xxx00.#####.ppt 11/21/13 09:43 PM
19. Skill Station Objectives
•Perform the placement of airway adjuncts and effective
BVM ventilation, at least twice, using an airway task trainer
while:
‐ Being instructed by your partner
‐ Describing each step in the process
•Explain how to determine the appropriate sized airway
adjuncts and BVM facemask according to anatomical
landmarks
•Assemble the AmbuBagTM from its component parts
Pediatrics
Page 19
xxx00.#####.ppt 11/21/13 09:43 PM
22. 3 Basic Components
•Most difficult airways can be recognized by 3
maneuvers:
‐ Examination of the oropharynx
‐ Evaluation of the range of motion at the atlanto-occipital
joint
‐ Measurement of the mandibular displacement area
Pediatrics
Page 22
xxx00.#####.ppt 11/21/13 09:43 PM
23. Examination of the oropharynx
•With mouth open to the fullest extent and tongue
maximally protruding you can assess:
‐ ROM at TMJ
‐ Size of tongue
‐ Palate
Pediatrics
Page 23
xxx00.#####.ppt 11/21/13 09:43 PM
24. Examination of the oropharynx
•Mallampati Classification: degree of airway
difficulty based on ability to visualize
‐ Soft palate
‐ Faucial pillars
‐ Uvula
Pediatrics
Page 24
xxx00.#####.ppt 11/21/13 09:43 PM
25. Range of motion at the AO joint
•Reduced ROM does not
allow alignment of airway
axes
Pediatrics
Page 25
xxx00.#####.ppt 11/21/13 09:43 PM
26. Mandibular Displacement Area
•Tongue & soft tissues must be displaced and
compressed into this space
•Adequate when distance between the anterior
ramus of the mandible and the hyoid bone is:
‐ 3 cm (2 finger breadths) in a child
‐ 1.5 cm in an infant
Pediatrics
Page 26
xxx00.#####.ppt 11/21/13 09:43 PM
27. Points of Emphasis: Oral Intubation
•Identify the potential for a difficult airway
•Check ALL of your equipment!!
•Pre-oxygenate
•Positioning
•Duration of suctioning (< 10 sec)
Pediatrics
Page 27
xxx00.#####.ppt 11/21/13 09:43 PM
28. Difficulty Viewing the Cords? BURP
• BURP vs. Sellick Maneuver (i.e. cricoid
pressure)
Image from: Carrillo-Esper et al. Rev Mex Anes. 2008
Pediatrics
Page 28
xxx00.#####.ppt 11/21/13 09:43 PM
29. Points of Emphasis: Oral Intubation
•Blade/ETT choice
- MacIntosh vs. Miller
- Cuffed vs. Uncuffed
•LIFT DON’T ROCK!!!
Pediatrics
Page 29
xxx00.#####.ppt 11/21/13 09:43 PM
41. Skill Station Objectives
•Carry out the proper sequence of steps involved in
orotracheal intubation, at least twice, using an airway task
trainer while:
‐ Being instructed by your partner
‐ Describing each step in the process
•Explain how to determine the appropriate ETT size for
orotracheal intubation using a formula and/or the patient’s
age/weight/size
•Determine the appropriate sized laryngoscopy blade
according to the patient’s age/weight/size
Pediatrics
Page 44
xxx00.#####.ppt 11/21/13 09:43 PM
42. Objectives
•Assess and discuss the need for Rapid Sequence
Intubation (RSI) given case-based examples
•Decide and discuss on an appropriate combination
of medications required for special intubating
situations given case-based examples
Pediatrics
Page 45
xxx00.#####.ppt 11/21/13 09:43 PM
43. Vignette 1
3 mos. old previously healthy infant presents with
bronchiolitis and requires intubation for impending
respiratory failure. Last fed breast milk 5 hrs ago.
‐What medications are you going to administer?
‐Why?
‐Requires RSI??
Pediatrics
Page 46
xxx00.#####.ppt 11/21/13 09:43 PM
45. Vignette 2
8 year old with ALL who presents with septic shock
and respiratory failure. HR = 150 and BP 80/35.
Drank a coke 3 hrs ago.
‐What medications are you going to administer?
‐Why?
‐What medications would you NOT give?
‐Requires RSI??
Pediatrics
Page 48
xxx00.#####.ppt 11/21/13 09:43 PM
47. Vignette 3
18 year old previously healthy male presents S/P
MVA. He acutely becomes altered with a GCS=7.
His HR is 120 and BP is 120/80.
‐What medications are you going to administer?
‐Why?
‐What medications would you NOT give?
‐Requires RSI??
Pediatrics
Page 50
xxx00.#####.ppt 11/21/13 09:43 PM
48. Premedicate (risk of increased ICP)
•+/-Atropine (0.02 mg/kg IV)
•Lidocaine (1mg/kg IV)
•Thiopental (3-5 mg/kg IV) – if hemodynamically
intact
OR
•Etomidate (0.25 mg/kg IV) – if hypotensive
Pediatrics
Page 51
xxx00.#####.ppt 11/21/13 09:43 PM
Hinweis der Redaktion
Different motif, more science
Text
Text
Text
Text
Text
Text
Text
Larynx is generally higher (cephalad) and more forward (anterior) in the neck than adults. This is more evident as you appreciate its position in relation to the C spine (GLOTTIS at C3-C4 in newborns, C4-C5 by 2 years of age, C5-C6 in adults)
Epiglottis is:
longer, floppier and more U-shaped
becomes more adult-like after 3 yo
Tongue:
Relatively large tongue
Conical larynx in AP dimension making the narrowest point of the airway at the level of the cricoid (until approx. 5 yrs of age), adults is cylindrical (narrowest at VC).
Larger adenoidal tissues: can contribute to airway obstruction and bleed if traumatized complicating airway management
Greater Raw bc R is inversely proportional to the fourth power of the radius (Poiseuille’s law). Thus even the slightest compromise in radius can cause significant Raw and increased WOB (when flow is laminar, ie at rest, fifth power when turbulent, ie agitation)
Faster falls in PaO2 during periods of apnea, i.e. for ETI, and/or resp compromise
Faster falls in PaO2 during periods of apnea, i.e. for ETI, and/or resp compromise
Any manipulation can cause compromise of airway patency Exam, O2 supplementation, suction, etc.
Any manipulation can cause airway compromise Exam, O2 supplementation, suction, etc.
Drooling may indicate epiglottitis and don’t want to be too aggressive with exam of oral cavity as it may cause complete obstruction
In this case should at least evaluate for trismus (spasm of jaw muscles)
If cervical spine suspected jaw thrust, which can also be performed with BVM ventilation
Different motif, more science
Text
Text
Text
With or without BMV
2nd bullet: esp NPA diameter
3rd bullet: larger pats, difficult airway, reduced lung compliance
One person lifts jaw and opens airway while other bags
B/L PTX, SC emphysema, pneumomediastinum
Elaborate
Also, while instructing, instruct how to troubleshoot, make corrections, etc.
Different motif, more science
Text
Text
Text
Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airway
FIRST THINGS FIRST:
2 extremes in time:
Elective (i.e. MAC) you have time to do full BAA
Emergent you don’t have the time, therefore, If emergent quickly perform a basic airway assessment (BAA) BEFORE intubation
Combination predicts adult difficult airway but no ped data
Class 1laryngoscopy yields adequate laryngeal exposure in >99% of adults
Class 3 is 7% adults
Not validated in children and has a high-false positive rate (50%) in identifying difficult pediatric airways
affects the ability to establish a line of sight to the glottic structures leading to an increased difficulty with intubation.
Mandibular space is of importance because the tongue and soft tissues must be displaced and compressed into this space
Potential displacement area is adequate when the distance between the anterior ramus of the mandible and the hyoid bone is…
If this space is small it will make laryngoscopy more difficult bc cannot align axes (laryngeal and pharyngeal axes make a more acute angle
Check functionality of laryngoscope/blade apparatus including light bulb, inflate cuff on ETT, check BVM apparatus, suction, etc.
Preoxygenate for at least 3 min
Positioning
Adjust the bed, if possible, so pt’s head is level with lower sternum
Sniffing position
Shoulder/head roll
Airway patency
Aligns all 3 axes to gain a line of vision from the mouth to the glottis
IN ALL AGES, axes are correctly aligned for ETI if external auditory canal is anterior to the front edge of the patients shoulders
Choice of blade
MacIntosh: curved blade is placed in the vallecula, at the base of the tongue, and used to indirectly lift the epiglottis from above.
Miller:
Infant/child epiglottis is floppy and elusive so straight blade may be safer for child <5yo but curve may also be used if > 2yo
blade to be positioned below the epiglottis, which is lifted directly.
****Although this provides an improved view of the larynx, it may stimulate the vagus nerve, which innervates the underside of the epiglottis, resulting in bradycardia.
Choosing an ETT
Historically taught that uncuffed tubes for <8 yo due to risk of subglottic injury and cricoid being the narrowest point. Thus an uncuffed tube should snugly fit into this area and create a satisfactory seal. With the improvement in materials used to construct the ETT and the advent of high volume/low pressure cuffs the former is not as likely. Data shows more use of cuffed ETT in children w/o the increased incidence of complications.
PROS: high inflation pressures may be required if lung compliance is reduced.
More consistent ventilation.
may be airway narrowing, and selecting the correct size for an uncuffed tube is complex and may require one or more tube changes,
Some protection against aspiration
CONS: require more care during use.
cuff pressure STILL need close attention to prevent pressure damage to the tracheal wall
must ensure the cuff is below the cricoid
Inflate cuff…: ETT>6.omm then use 10 ml syringe, less than that 5ml should be sufficient
Last bullet: Stylet should be approx 1 cm from the end of the ETT
Bend tube into gentle curve or at tip so when inserted it is aimed anteriorly esp for infants with higher/anterior airways
Inflate cuff: A pressure of 20cm H2O is sufficient to provide a seal, but does not compromise mucosal blood flow. Tracheal mucosal blood flow is compromised at 30 cm water pressure, and mucosal blood flow is completely obstructed at pressures of 45 cm water
Complications:
Malposition
CONFIRMATION:
CO2 detector: color change from purple to yellow. Bag for 6 breaths
Auscultation: listen over stomach first then B/L mid axillary lung fields. Esophageal intubation if gurgling sounds heard, BS can be transmitted. Give time for oxygenation to improve
NOT SENSITIVE WITH NON PERFUSING RHYTHM!!!
If ped used in adults take out after 6 breaths due to Raw
If adults used in peds take out after 6 breaths bc of dead space
Right mainstem
Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.
