Pediatric Airway Management Dr. Shapiro I., PICU Dec 2003
Adult Chain of Survival Early Defibrillation CPR ALS EMS
Pediatric Chain of Survival Prevention ALS CPR EMS
Out-of-Hospital Cardiac Arrest <ul><li>SIDS </li></ul><ul><li>Trauma </li></ul><ul><li>Submersion </li></ul><ul><li>Poison...
In-Hospital Cardiac Arrest <ul><li>Sepsis </li></ul><ul><li>Respiratory Failure </li></ul><ul><li>Drug Toxicity </li></ul>...
Pediatric  Cardiorespiratory Arrests 10% 10% 80%
Pediatric  Cardiorespiratory Arrests Hypoxia and Hypercarbia Bradycardia RESPIRATORY ARREST CARDIOPULMONARY ARREST
Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335 : 1473-147...
Survival from Respiratory Arrest Respiratory Arrest Alone – more than 50%  neurologically intact  survival rate
Pediatric Chain of Survival Prevention ALS CPR EMS
To Simplify the Message… Early Defibrillation 8 years Age With exceptions… (submersion, trauma, drug overdose) With except...
PREVENTION 1992 SIDS SIDS More Than 50%... &quot;BACK TO SLEEP&quot;
Respiratory Distress Respiratory Failure and Respiratory Arrest BLS
Evaluation of Respiratory Performance <ul><li>Respiratory Rate and Regularity </li></ul><ul><li>Level of Consciousness </l...
Respiratory Mechanics <ul><li>Head Bobbing </li></ul><ul><li>Nasal Flaring </li></ul><ul><li>Retractions </li></ul><ul><li...
Upper Airway Obstruction turbulence
Lower Airway Obstruction turbulence & wheezing
Anatomy Children are very different than adults !!!
Anatomy  :   Airway Nose  Tongue Epiglottis  Vocal Cords Larynx
Anatomy: Larynx <ul><li>Narrowest point = cricoid cartilage </li></ul>INFANT ADULT
Physiology <ul><li>Tongue - Posterior Displacement </li></ul><ul><li>Tongue – Difficult to Control </li></ul><ul><li>Epigl...
Effect Of Edema Poiseuille’s law
Basic Life Support A+B
Two Steps Before… <ul><li>1. Ensure the Safety of Rescuer and Victim </li></ul><ul><li>( the scene, gloves, barrier device...
Airway Head Tilt-Chin Lift Jaw Thrust + Tongue-Jaw Lift Maneuver (FBAO)
Breathing <ul><li>Check Breathing </li></ul>Look Listen Feel Recovery Position Rescue Breathing
Ventilation with Oxygen <ul><li>Mouth-to-Mouth ventilation provides  only 17% O 2 </li></ul><ul><li>Indicated to all serio...
Devices to Monitor Respiratory Function <ul><li>Pulse Oxymetry </li></ul><ul><li>End-Tidal CO 2 </li></ul><ul><li>Arterial...
Oxygen Delivery Systems <ul><li>Oxygen Mask </li></ul><ul><li>Face Tent </li></ul><ul><li>Oxygen Hood </li></ul><ul><li>Ox...
Oropharyngeal Airway SIZE PROPER POSITION
Nasopharyngeal Airway
Nasopharyngeal Airway
Bag-Mask Ventilation Proper area for mask application
Bag-Mask Ventilation Sellick Maneuver
Laryngeal Mask Contraindicated if gag-reflex is intact Higher success rate Does NOT protect from aspiration Difficult to m...
Intubation
Intubation: Indications <ul><li>Failure to oxygenate </li></ul><ul><li>Failure to remove CO 2 </li></ul><ul><li>Increased ...
Tracheal Tube Children > 2 years: ETT size:  (Age+16)/4 ETT depth (lip):  ETTsize x 3 Age kg ETT   Length Newborn 3.5 3.5 ...
Laryngoscope Blades Better in younger children with a floppy epiglottis Straight
Laryngoscope Blades Better in older children who have a stiff epiglottis Curved
Intubation Technique
Confirmation  of ETT Placement <ul><li>NO  single technique is 100% reliable </li></ul><ul><li>Clinical Confirmation </li>...
Clinical Confirmation <ul><li>Chest rise </li></ul><ul><li>Water vapor seen inside tube </li></ul><ul><li>Breath sounds - ...
Acute Deterioration after Intubation <ul><li>D.O.P.E :   D isplacement </li></ul><ul><ul><ul><ul><ul><li>O bstruction </li...
Inadequate Improvement after Intubation <ul><li>Inadequate Tidal Volume </li></ul><ul><li>Excessive Leak Around The Tube <...
Percutaneous  Cricothyrotomy <ul><li>Complete UA Obstruction: </li></ul><ul><li>FBAO </li></ul><ul><li>Severe Orofacial In...
<ul><li>See You at Next Week’s Workshop </li></ul><ul><li>Happy Khanukka </li></ul>
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  • Adult – VF or Pulseless VT
  • If asystolic, mortality &gt; 90%
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  • Pediatric airway management shapiro

    1. 1. Pediatric Airway Management Dr. Shapiro I., PICU Dec 2003
    2. 2. Adult Chain of Survival Early Defibrillation CPR ALS EMS
    3. 3. Pediatric Chain of Survival Prevention ALS CPR EMS
    4. 4. Out-of-Hospital Cardiac Arrest <ul><li>SIDS </li></ul><ul><li>Trauma </li></ul><ul><li>Submersion </li></ul><ul><li>Poisoning </li></ul><ul><li>Choking </li></ul><ul><li>Severe Asthma </li></ul><ul><li>Pneumonia </li></ul>
    5. 5. In-Hospital Cardiac Arrest <ul><li>Sepsis </li></ul><ul><li>Respiratory Failure </li></ul><ul><li>Drug Toxicity </li></ul><ul><li>Metabolic Disorder </li></ul><ul><li>Arrhythmias </li></ul>
    6. 6. Pediatric Cardiorespiratory Arrests 10% 10% 80%
    7. 7. Pediatric Cardiorespiratory Arrests Hypoxia and Hypercarbia Bradycardia RESPIRATORY ARREST CARDIOPULMONARY ARREST
    8. 8. Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335 : 1473-1479 Arrive in ER in cardiac arrest (N = 80) Admit PICU (N=43) 54 % Died in ER (N=37) 46% Mod Deficit (N=3) PVS at 12 mos (N=2) Dead at 12 mos (N=1) Died in ICU (N=37) 46% Outcome of cardiac arrest in children
    9. 9. Survival from Respiratory Arrest Respiratory Arrest Alone – more than 50% neurologically intact survival rate
    10. 10. Pediatric Chain of Survival Prevention ALS CPR EMS
    11. 11. To Simplify the Message… Early Defibrillation 8 years Age With exceptions… (submersion, trauma, drug overdose) With exceptions… (sudden collapse, cardiac history)
    12. 12. PREVENTION 1992 SIDS SIDS More Than 50%... &quot;BACK TO SLEEP&quot;
    13. 13. Respiratory Distress Respiratory Failure and Respiratory Arrest BLS
    14. 14. Evaluation of Respiratory Performance <ul><li>Respiratory Rate and Regularity </li></ul><ul><li>Level of Consciousness </li></ul><ul><li>Color of the Skin and Mucous Membranes </li></ul><ul><li>Respiratory Mechanics </li></ul>
    15. 15. Respiratory Mechanics <ul><li>Head Bobbing </li></ul><ul><li>Nasal Flaring </li></ul><ul><li>Retractions </li></ul><ul><li>Grunting </li></ul><ul><li>Stridor </li></ul><ul><li>Wheezing or Prolonged Exhalation </li></ul>
    16. 16. Upper Airway Obstruction turbulence
    17. 17. Lower Airway Obstruction turbulence & wheezing
    18. 18. Anatomy Children are very different than adults !!!
    19. 19. Anatomy : Airway Nose Tongue Epiglottis Vocal Cords Larynx
    20. 20. Anatomy: Larynx <ul><li>Narrowest point = cricoid cartilage </li></ul>INFANT ADULT
    21. 21. Physiology <ul><li>Tongue - Posterior Displacement </li></ul><ul><li>Tongue – Difficult to Control </li></ul><ul><li>Epiglottis – Difficult to Control </li></ul><ul><li>Vocal Cords – Difficult Intubation </li></ul><ul><li>Tube size relative to Cricoid Diameter </li></ul><ul><li>Small Airway Edema causes High Resistance </li></ul>
    22. 22. Effect Of Edema Poiseuille’s law
    23. 23. Basic Life Support A+B
    24. 24. Two Steps Before… <ul><li>1. Ensure the Safety of Rescuer and Victim </li></ul><ul><li>( the scene, gloves, barrier devices) </li></ul><ul><li>“ Partial” CPR: Is Something Better than Nothing? </li></ul>2. Stimulate and Check Responsiveness
    25. 25. Airway Head Tilt-Chin Lift Jaw Thrust + Tongue-Jaw Lift Maneuver (FBAO)
    26. 26. Breathing <ul><li>Check Breathing </li></ul>Look Listen Feel Recovery Position Rescue Breathing
    27. 27. Ventilation with Oxygen <ul><li>Mouth-to-Mouth ventilation provides only 17% O 2 </li></ul><ul><li>Indicated to all seriously ill or injured patients even if pCO 2 is high </li></ul><ul><li>If Possible – humidify Oxygen </li></ul><ul><li>Use of reduced FiO 2 is uncommon </li></ul>
    28. 28. Devices to Monitor Respiratory Function <ul><li>Pulse Oxymetry </li></ul><ul><li>End-Tidal CO 2 </li></ul><ul><li>Arterial Blood Gas Analysis </li></ul>
    29. 29. Oxygen Delivery Systems <ul><li>Oxygen Mask </li></ul><ul><li>Face Tent </li></ul><ul><li>Oxygen Hood </li></ul><ul><li>Oxygen Tent </li></ul><ul><li>Nasal Canula </li></ul>
    30. 30. Oropharyngeal Airway SIZE PROPER POSITION
    31. 31. Nasopharyngeal Airway
    32. 32. Nasopharyngeal Airway
    33. 33. Bag-Mask Ventilation Proper area for mask application
    34. 34. Bag-Mask Ventilation Sellick Maneuver
    35. 35. Laryngeal Mask Contraindicated if gag-reflex is intact Higher success rate Does NOT protect from aspiration Difficult to maintain during transport
    36. 36. Intubation
    37. 37. Intubation: Indications <ul><li>Failure to oxygenate </li></ul><ul><li>Failure to remove CO 2 </li></ul><ul><li>Increased WOB </li></ul><ul><li>Neuromuscular weakness </li></ul><ul><li>CNS failure </li></ul><ul><li>Cardiovascular failure </li></ul>
    38. 38. Tracheal Tube Children > 2 years: ETT size: (Age+16)/4 ETT depth (lip): ETTsize x 3 Age kg ETT Length Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12
    39. 39. Laryngoscope Blades Better in younger children with a floppy epiglottis Straight
    40. 40. Laryngoscope Blades Better in older children who have a stiff epiglottis Curved
    41. 41. Intubation Technique
    42. 42. Confirmation of ETT Placement <ul><li>NO single technique is 100% reliable </li></ul><ul><li>Clinical Confirmation </li></ul><ul><li>Chest X-ray </li></ul><ul><li>CO2 Detection </li></ul><ul><li>Esophageal Detector Devices </li></ul>
    43. 43. Clinical Confirmation <ul><li>Chest rise </li></ul><ul><li>Water vapor seen inside tube </li></ul><ul><li>Breath sounds - lung </li></ul><ul><li>Breath sounds – epigastrium </li></ul><ul><li>O 2 Saturation </li></ul>
    44. 44. Acute Deterioration after Intubation <ul><li>D.O.P.E : D isplacement </li></ul><ul><ul><ul><ul><ul><li>O bstruction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>P neumothorax </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>E quipment failure </li></ul></ul></ul></ul></ul>
    45. 45. Inadequate Improvement after Intubation <ul><li>Inadequate Tidal Volume </li></ul><ul><li>Excessive Leak Around The Tube </li></ul><ul><li>Air Trapping and Impaired Cardiac Output </li></ul><ul><li>Leak or Disconnection in Ventilator System </li></ul><ul><li>Inadequate PEEP </li></ul><ul><li>Inadequate O 2 Flow from Gas Source </li></ul>
    46. 46. Percutaneous Cricothyrotomy <ul><li>Complete UA Obstruction: </li></ul><ul><li>FBAO </li></ul><ul><li>Severe Orofacial Injuries </li></ul><ul><li>Upper Airway Infections </li></ul>
    47. 47. <ul><li>See You at Next Week’s Workshop </li></ul><ul><li>Happy Khanukka </li></ul>
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