App ped aw course1


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  • Different motif, more science
  • 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
    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
  • 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
  • Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airway
    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 1laryngoscopy 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
    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.
    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
    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
    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.
  • Volume load also!!!
  • App ped aw course1

    1. 1. Pediatric Airway Management for the Advanced Practice Provider Pediatrics
    2. 2. Course Outline •Pediatric airway anatomy/physiology •Points of emphasis/Discussion ‐ Airway adjuncts ‐ BVM ventilation ‐ Orortracheal intubation •Skill stations •Case-based performance Pediatrics Page 2 xxx00.#####.ppt 11/21/13 09:43 PM
    3. 3. The Pediatric Airway Anatomy & Physiology Pediatrics
    4. 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. 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
    6. 6. Pediatric vs. Adult Airway Pediatrics Page 6 xxx00.#####.ppt 11/21/13 09:43 PM
    7. 7. Pediatric vs. Adult Airway •Conical larynx • Narrowest point @ cricoid ring •Larger occiput •Compliant and distensible large airways Pediatrics Page 7 xxx00.#####.ppt 11/21/13 09:43 PM
    8. 8. Pediatric vs. Adult Airway •Larger adenoidal tissues •Narrower tracheal diameter and shorter tracheal length •Narrower larger airways Pediatrics Page 8 xxx00.#####.ppt 11/21/13 09:43 PM
    9. 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. 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. 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. 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. 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
    14. 14. Pediatric Airway Management Airway Adjuncts and Bag-ValveMask Ventilation Pediatrics
    15. 15. Points of Emphasis: Airway Adjuncts •Ensure airway patency ‐ Positioning ‐ Repositioning ‐ Suctioning ‐ Head/shoulder roll •Be careful in sizing •Insertion technique ‐ 3rd option Pediatrics Page 15 xxx00.#####.ppt 11/21/13 09:43 PM
    16. 16. Points of Emphasis: BVM Ventilation •True life saving technique •Utilize airway adjuncts •Utilize two-person technique •“Effective” = Chest Rise •Excessive bagging due to user exuberance ‐ Gastric distension ‐ Barotrauma Pediatrics Page 16 xxx00.#####.ppt 11/21/13 09:43 PM
    17. 17. Pediatrics Page 17 xxx00.#####.ppt 11/21/13 09:43 PM
    18. 18. Points of Emphasis: BVM Ventilation From: Lee et al. Korean J Anesthesiol 2010 (Left); (Right) Pediatrics Page 18 xxx00.#####.ppt 11/21/13 09:43 PM
    19. 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
    20. 20. Pediatric Airway Management Orotracheal Intubation Pediatrics
    21. 21. 1st Commandment Pediatrics Page 21 xxx00.#####.ppt 11/21/13 09:43 PM
    22. 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. 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. 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. 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. 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. 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. 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. 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
    30. 30. Points of Emphasis: Oral Intubation •Confirmation -CO2 Detector •Post-Intubation Care - PressureEasyTM •Complications Pediatrics Page 32 xxx00.#####.ppt 11/21/13 09:43 PM
    31. 31. Pediatrics Page 34 xxx00.#####.ppt 11/21/13 09:43 PM
    32. 32. Pediatrics Page 35 xxx00.#####.ppt 11/21/13 09:43 PM
    33. 33. Pediatrics Page 36 xxx00.#####.ppt 11/21/13 09:43 PM
    34. 34. Pediatrics Page 37 xxx00.#####.ppt 11/21/13 09:43 PM
    35. 35. Pediatrics Page 38 xxx00.#####.ppt 11/21/13 09:43 PM
    36. 36. Pediatrics Page 39 xxx00.#####.ppt 11/21/13 09:43 PM
    37. 37. Pediatrics Page 40 xxx00.#####.ppt 11/21/13 09:43 PM
    38. 38. Pediatrics Page 41 xxx00.#####.ppt 11/21/13 09:43 PM
    39. 39. Pediatrics Page 42 xxx00.#####.ppt 11/21/13 09:43 PM
    40. 40. Pediatrics Page 43 xxx00.#####.ppt 11/21/13 09:43 PM
    41. 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. 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. 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
    44. 44. Premedicate (typical) •Atropine (0.02 mg/kg IV) •Midazolam (0.1-0.2 mg/kg IV/IM/IN) •Fentanyl (2-4 mcg/kg IV) •Rocuronium (1.2-1.5 mg/kg IV) Pediatrics Page 47 xxx00.#####.ppt 11/21/13 09:43 PM
    45. 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
    46. 46. Premedication (alternative/sepsis) •+/- Atropine (0.02 mg/kg IV) •Ketamine (1-3 mg/kg IV) •Rocuronium (1.2-1.5 mg/kg IV) Pediatrics Page 49 xxx00.#####.ppt 11/21/13 09:43 PM
    47. 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. 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
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