Pediatric Airway
Management
Pediatrics
Objectives
By the end of this workshop, the learner will:
‐ Recite at least 3 indications and 5 complications
associated w...
Preparing for Intubation

Pediatrics
Indications for Intubation
• Primary respiratory disorder
‐ Severe hypoxemia (pneumonia, ARDS)
‐ Severe hypoventilation (b...
Use SOAP to Prepare for Intubation
‐ Rigid catheter with constant suction (Yankauer)

•Oxygen
‐ 10-15 LPM 100% (make sure ...
Medications for Intubation
•Premedication for laryngoscopy
•Sedation +/- analgesia
•Neuromuscular blockade
‐ Make sure you...
Premedication
•Atropine (neonates, infants)
‐ 0.02 mg/kg IV (0.1 – 1 mg total dose)
‐ Blunts the vagal response from laryn...
Sedation
• Ketamine (shock states, asthma)

• Midazolam (85% of routine
patients)

‐ 1 – 3 mg/kg IV (may cause
increased b...
Neuromuscular Blockade
• Rocuronium vs. Vecuronium (85% • Succinylcholine
of patients)
‐ 1 – 2 mg/kg IV; 4 mg/kg IM
‐ Rocu...
Orotracheal Intubation

Pediatrics
Laryngoscope and ETT Selection
•Match the patient! If the patient is smaller than stated age
(or unknown age), ETT can be ...
Choose Your Blades
Miller Blades

Pediatrics

Macintosh Blades

Page 12
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Head Tilt-Chin Lift Maneuver

http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259

Pediatrics

Page 13
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Alignment of The Airway:
Children <3 years
O: Oral axis
P: Pharyngeal axis
L: Laryngeal axis

Large occiput
flexes head an...
Placement of the Laryngoscope
Blade (< 3 years)

Shoulder Roll for Infants
From: Foltin et al (eds). Teaching Resource for...
Alignment of The Airway:
Children >3 years
O: Oral axis
P: Pharyngeal axis
L: Laryngeal axis

Cushion under head
will flex...
Placement of the Laryngoscope
Blade (> 3 years)

From: Foltin et al (eds). Teaching Resource for Instructors in Prehospita...
Laryngoscopic View

From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 19...
ETT Insertion Depth – How Far?
•3 x ETT size
•Black marking or cuff past vocal cords

Pediatrics

Page 19
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Post-Intubation Care

Pediatrics
How Do You Confirm Intubation?
• Bilateral & equal breath sounds

• CXR confirmation

- If decreased on one side?

• Absen...
Potential Complications of Oral
Intubation
•Inability to ventilate (difficulty intubating and cannot BMV)
‐ This can lead ...
Potential Complications of Oral
Intubation
•Airway trauma
‐ Teeth (check for loose or missing teeth before and after)
‐ Vo...
Pneumothorax

From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)

Pediatrics

Page 24
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Dental Trauma (DON’T DO THIS)

From: Windsor and Lockie. Anaesth and Int Care Med. 2008

Pediatrics

Page 25
xxx00.#####.p...
NOW WATCH IT DONE

Pediatrics
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  • Different motif, more science
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    1. 1. Pediatric Airway Management Pediatrics
    2. 2. Objectives By the end of this workshop, the learner will: ‐ Recite at least 3 indications and 5 complications associated with orotracheal intubation ‐ Derive 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 ‐ Carry out the proper sequence of events involved in orotracheal intubation Pediatrics Page 2 xxx00.#####.ppt 11/21/13 04:42 AM
    3. 3. Preparing for Intubation Pediatrics
    4. 4. Indications for Intubation • Primary respiratory disorder ‐ Severe hypoxemia (pneumonia, ARDS) ‐ Severe hypoventilation (bronchiolitis, emphysema, CLD) • Primary neuromuscular disorder ‐ Myopathy (DMD, SMA) ‐ Altered mental status with hypoventilation (TBI, intoxication) ‐ Lack of airway protection (TBI, severe HIE, intoxication) ‐ Need for sedation with risk of airway protection or ventilation • Tight control of paCO2 or pH ‐ Severe increased ICP (paCO2) ‐ Severe pulmonary hypertension (pH) • To reduce metabolic demands in severe shock Pediatrics Page 4 xxx00.#####.ppt 11/21/13 04:42 AM
    5. 5. Use SOAP to Prepare for Intubation ‐ Rigid catheter with constant suction (Yankauer) •Oxygen ‐ 10-15 LPM 100% (make sure it is not on a blender) •Airway ‐ Appropriate sized tubes (estimated size and ½ size smaller) ‐ Appropriate sized laryngoscope blades ‐ Airway adjuncts •Pharmacology Pediatrics Page 5 xxx00.#####.ppt 11/21/13 04:42 AM www.mountainside‐medical.com/products/Yankauer‐Suction‐Tip‐Handle.html •Suction
    6. 6. Medications for Intubation •Premedication for laryngoscopy •Sedation +/- analgesia •Neuromuscular blockade ‐ Make sure you can ventilate prior to neuromuscular blockade ‐ Make sure you can ventilate prior to neuromuscular blockade ‐ Make sure you can ventilate prior to neuromuscular blockade Pediatrics Page 6 xxx00.#####.ppt 11/21/13 04:42 AM
    7. 7. Premedication •Atropine (neonates, infants) ‐ 0.02 mg/kg IV (0.1 – 1 mg total dose) ‐ Blunts the vagal response from laryngoscopy ‐ Use if bradycardic/risk of bradycardia •Lidocaine (TBI, elevated ICP) ‐ 1 mg/kg IV ‐ Anesthetizes airway to blunt the ICP spike from laryngoscopy Pediatrics Page 7 xxx00.#####.ppt 11/21/13 04:42 AM
    8. 8. Sedation • Ketamine (shock states, asthma) • Midazolam (85% of routine patients) ‐ 1 – 3 mg/kg IV (may cause increased bronchorrhea) ‐ 0.1 – 0.2 mg/kg IV ‐ 2 mg/kg IV for RSI • Fentanyl (85% of routine patients) ‐ 2 – 6 mcg/kg IV (slow infusion, may cause rigid chest) • Thiopental vs. Etomidate (elevated ICP) ‐ Thiopental 3 – 5 mg/kg IV (high risk of hypotension) ‐ Give sedative with fentanyl (no sedative effect) ‐ Etomidate 0.2 – 0.6 mg/kg IV (may cause adrenal suppression) • Propofol ‐ 1 mg/kg IV (may cause hypotension) Pediatrics Page 8 xxx00.#####.ppt 11/21/13 04:42 AM
    9. 9. Neuromuscular Blockade • Rocuronium vs. Vecuronium (85% • Succinylcholine of patients) ‐ 1 – 2 mg/kg IV; 4 mg/kg IM ‐ Rocuronium 0.6 – 1.2 mg/kg IV (1.5 – 2 mg/kg IV for RSI) ‐ Patient will fasciculate, consider a defasciculating dose of rocuronium/vecuronium (1/10 dose) ‐ Vecuronium 0.1 – 0.4 mg/kg IV ‐ Effect may be prolonged in renal/hepatic failure ‐ Beware of hyperkalemia in patients with neuromuscular disorders, burns, crush injuries, renal failure • Cisatracurium ‐ 0.2 mg/kg IV ‐ Cleared by Hoffman degradation (good for renal/hepatic failure) Pediatrics Page 9 xxx00.#####.ppt 11/21/13 04:42 AM
    10. 10. Orotracheal Intubation Pediatrics
    11. 11. Laryngoscope and ETT Selection •Match the patient! If the patient is smaller than stated age (or unknown age), ETT can be estimated by the patient’s 5 th finger size Age Blade Size & Type ETT Size (mm; Uncuffed & Cuffed) NB < 2 kg 0 Miller 2.5 NB > 2 kg ~ 6 mo 1 Miller 3.5 or 3.0 C 6 mo ~ 1 yr 1 ~ 1.5 Miller 4.0 or 3.5 C 1 yr ~ 2 yr 1.5 Miller 4.5 or 4.0 C 2 yr ~ 8 yr 2 Miller For UNcuffed tubes: 8 yr ~ 12 yr 2 Miller or 2 Macintosh > 12 yr 3 Miller or 3 Macintosh Pediatrics Age(yrs) +4 4 Page 11 xxx00.#####.ppt 11/21/13 04:43 AM Subtract 0.5 mm for Cuffed tubes
    12. 12. Choose Your Blades Miller Blades Pediatrics Macintosh Blades Page 12 xxx00.#####.ppt 11/21/13 04:42 AM
    13. 13. Head Tilt-Chin Lift Maneuver http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259 Pediatrics Page 13 xxx00.#####.ppt 11/21/13 04:43 AM
    14. 14. Alignment of The Airway: Children <3 years O: Oral axis P: Pharyngeal axis L: Laryngeal axis Large occiput flexes head and neck Shoulder roll will help line up the pharyngeal and laryngeal axes Extension of atlantooccipital joint will line up oral axis with the other two McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249‐84 Pediatrics Page 14 xxx00.#####.ppt 11/21/13 04:43 AM
    15. 15. Placement of the Laryngoscope Blade (< 3 years) Shoulder Roll for Infants From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001 Pediatrics Page 15 xxx00.#####.ppt 11/21/13 04:42 AM
    16. 16. Alignment of The Airway: Children >3 years O: Oral axis P: Pharyngeal axis L: Laryngeal axis Cushion under head will flex neck to line up pharyngeal and laryngeal axes Extension of atlantooccipital joint will line up oral axis with the other two McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84 Pediatrics Page 16 xxx00.#####.ppt 11/21/13 04:42 AM
    17. 17. Placement of the Laryngoscope Blade (> 3 years) From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001 Pediatrics Page 17 xxx00.#####.ppt 11/21/13 04:42 AM
    18. 18. Laryngoscopic View From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right) Pediatrics Page 18 xxx00.#####.ppt 11/21/13 04:42 AM
    19. 19. ETT Insertion Depth – How Far? •3 x ETT size •Black marking or cuff past vocal cords Pediatrics Page 19 xxx00.#####.ppt 11/21/13 04:42 AM
    20. 20. Post-Intubation Care Pediatrics
    21. 21. How Do You Confirm Intubation? • Bilateral & equal breath sounds • CXR confirmation - If decreased on one side? • Absent sounds over stomach - If absent on one side and hypertympanic • Improvement of oxygenation • Mist in ETT during bagventilation - If saturations rapidly decrease? •EtCO2 confirmation - Colorimetric: Yellow = Yes - Waveform analysis/quantitative: > 15 mm Hg Pediatrics Page 21 xxx00.#####.ppt 11/21/13 04:43 AM
    22. 22. Potential Complications of Oral Intubation •Inability to ventilate (difficulty intubating and cannot BMV) ‐ This can lead to death ‐ Make sure you can ventilate prior to neuromuscular blockade •Tube malposition (esophageal intubation) ‐ What will you notice/see? Pediatrics Page 22 xxx00.#####.ppt 11/21/13 04:42 AM
    23. 23. Potential Complications of Oral Intubation •Airway trauma ‐ Teeth (check for loose or missing teeth before and after) ‐ Vocal cord injury (ineffective paralytic/VC closed during insertion) ‐ Subglottic edema/stenosis (incorrect tube size) •Pulmonary disease ‐ Mainstem (left or right) intubation ‐ Pneumothorax (usually from over-exuberant bagging) Pediatrics Page 23 xxx00.#####.ppt 11/21/13 04:42 AM
    24. 24. Pneumothorax From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right) Pediatrics Page 24 xxx00.#####.ppt 11/21/13 04:42 AM
    25. 25. Dental Trauma (DON’T DO THIS) From: Windsor and Lockie. Anaesth and Int Care Med. 2008 Pediatrics Page 25 xxx00.#####.ppt 11/21/13 04:42 AM
    26. 26. NOW WATCH IT DONE Pediatrics
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