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Pediatric airway management
This document provides an overview of pediatric airway management techniques. It discusses various oxygen delivery devices including nasal cannulas, simple oxygen masks, and non-rebreathing masks. Bag-valve mask ventilation is described including proper positioning and techniques. Intubation is covered, including equipment selection, laryngoscopy techniques, and confirmation of proper tube placement. Rescue airway devices like LMAs, Combitubes, and bougies are also summarized. Key rules for managing the pediatric airway emphasize being prepared, having backup plans, using common sense, and individualizing approaches for each patient.
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Pediatric airway management
- 1. PEDIATRIC AIRWAY TECHNIQUE DR ABDUL RUB MEM PGY2 MISSION HOSPITAL
- 2. Devices Nasalcannula Simple O2 Mask Non- rebreathing mask Bag valve mask ventilation Intubation OTHERS…..
- 3. Nasal Cannula FiO2 0.22-0.40 Prongs should not completely occlude the nares-multiple sizes available **Ensure pt nares are patent** Use with bubble humidifier
- 4. Nasal Cannula Sizes Size Max Flow Premature (< term) 2 LPM Neonate (>1400 g) 2 LPM Infant (newborn, term) 2 LPM Intermediate Infant (3-12 mo) 2 LPM Pediatric (>1yr) 3 LPM
- 5. Simple O2 Mask • FiO2 0.35-0.50 • ****Minimum 5 LPM O2 flow!!!!****** • Can’t really titrate O2 • Pt can’t eat/ drink • Use with bubble humidifier • Gently press on metal bar to conform to pt’s face. Do NOT pinch!
- 7. Partial Non- RebreathingMask FiO2 0.60-0.90 (depending on mask fit) Minimum 5 LPM for infant/child, 10 LPM for teens. Match flow to need Reservoir bag and one-way valve limit amount of RA inspired and ↓ dilution of FiO2 Gently press on metal bar to conform to pt’s face. Do NOT pinch!
- 9. Estimating FiO2 O2Flow rate FiO2 O2 Flow rate FiO2 O2 Flow rate FiO2 Nasal cannula Oxygen mask Mask with reservoir 1 0.24 5-6 0.4 6 0.6 2 0.28 6-7 0.5 7 0.7 3 0.32 7-8 0.6 8 0.8 4 0.36 9 0.80+ 5 0.4 10 0.80+ 6 0.44
- 10. Oropharyngeal Airway SIZE PROPER POSITION Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
- 11. Choosing correct OPA Place OPA against side of face. With flange at the corner of the mouth the tip should reach angle of the jaw Too small: will not adequately displace tongue Too large: may obstruct larynx and/ or interfere with mask fit if BVM required
- 12. Nasopharyngeal Airways Soft plastic pre-made or shortened ETT Provides unobstructed path for airflow between nares and pharynx Can use in conscious/ semi-conscious pt Small internal diameter so must be evaluated frequently and suctioned prn to maintain patency
- 13. Nasopharyngeal Airway •Distancefrom nares to angle of mandible approximates the proper length •Nasopharyngeal airway available in 12F to 36F sizes •Shortened endotracheal tube may be used in infants or small children •Avoid placement in cases of hypertrophied adenoids - bleeding and trauma Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
- 15. Appropriate Size isKey Correct size Incorrect size (Atlas of Airway
- 16. OXYGEN TENT CLEARPLASTIC SHELL THAT COVERS THE PATIENTS UPPER BODY PROVIDES MORE THAN 50% OF O2 NOT RELIABLE ACESSES TO CHILD LIMITED CAN NOT BE USED IN EMERGENCY SITUATION
- 17.
- 18. **Multiple Mask sizesavailable so choose the correct one**
- 19. Infants: Want exteriorear canal to be anterior to the shoulder shoulder roll works best for positioning infants and small children
- 20. Bag-Mask Ventilation Indicated when the pt’s spontaneous breathing effort is inadequate despite patent airway Can provide adequate oxygenation and ventilation until definitive airway control is obtained Can be as effective as ventilation through ETT
- 21. Bagging Units 3 sizes: Age Volume (ml) Infant 500 Child 1000 Adolescent 2000
- 22. Testing the baggingunit Check all components before use to ensure proper function. Ideally as part of your daily safety checks. Occlude pt outlet and outflow, squeeze bag ensure no tears/leaks Ensure connection to wall O2 and adequate flow Proper size mask with cuff inflated
- 23. Bag-Mask Ventilation Sellick Maneuver Breathing
- 25. Bagging 1. Positionpt: sniffing position 2. Open airway and seal mask to face using E-C technique. You may need OPA. 3. Squeeze bag with other hand to deliver tidal volume and produce chest rise. Careful to not over-ventilate!
- 26. 2 person BMV One person uses both hands to open airway and maintain tight mask-to-face seal 2nd person bags
- 27. Monitor effectiveness of Ventilation Visible chest rise with each breath SpO2 ETCO2 HR BP Pt responsiveness Air entry on auscultation
- 28. If ventilation isnot effective… Reposition pt. Reposition airway. OPA. Verify proper mask size and placement Suction airway Check O2 source and flow Check bag and mask for function/leaks Treat gastric inflation
- 29. If these don’twork… Pt may require more advanced interventions to establish a patent airway CPAP Intubation
- 30. Sniffing Position Patientflat on operating ttaabbllee,, tthhee oorraall ((oo)),, pphhaarryynnggeeaall ((PP)),, aanndd ttrraacchheeaall ((TT)) aaxxiiss ppaassss tthhrroouugghh tthhrreeee ddiivveerrggeenntt ppllaanneess AA bbllaannkkeett ppllaacceedd uunnddeerr tthhee oocccciippuutt aalliiggnnss tthhee pphhaarryynnggeeaall ((PP)) aanndd ttrraacchheeaall ((TT)) aaxxeess EExxtteennssiioonn ooff tthhee aattllaannttoo--oocccciippiittaall jjooiinntt aalliiggnnss tthhee oorraall ((OO)),, pphhaarryynnggeeaall ((PP)),, aanndd ttrraacchheeaall ((TT)) aaxxeess Image from: http://depts.Washington.edu/pccm/Pediatric%20Airway %20management.ppt
- 31. Preparing for Intubation Appropriate ETT for >1 yo: (age/4) + 4 Term infant: 3.0-3.5 ID 6 mo: 3.5-4.0 ID 1 yo: 4.0-4.5 ID Cuffed ETT’s for pt’s > 8 yo If you anticipate need for high PEEP or PIP may want to use cuffed ETT with <8 yo. Use ½ size smaller ETT. Remember SOAPME
- 32. Tracheal Tube Sizes Insufflation Pressure ? Muscle Relaxants? Age (Size (mm ID Insertion length (Alveolar ridge( Preterm 1000g Preterm 1000-2500g 2.5 3.0 cm 6-9 Neonate-6 Month 3.0-3.5 cm 10 Month – 1 Yr 6 3.5-4.0 cm 11 Yrs 1-2 4.0-5.0 cm 12 Beyond 2 Yrs age (yrs(/4 + 4 age (yrs(/2 + 12
- 33. Equipment: Blade and Tube Size Age Blade/Size Infant Miller 1 2 years old Miller 2 12 years old Miller/Mac 3 “Switch to a 2 at 2”
- 34. Intubation - Techniques Always enter from the right corner Tongue control is critical Lift the epiglottis with the Miller Slide the Mac into the vallecula Can lift the epiglottis if needed
- 35.
- 36. Curved blade technique a) Open the patient's mouth with the right hand, . b) Grasp the laryngoscope in the left hand c) Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth. d) Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left. e) Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.
- 37. Curved blade technique f) take the endotracheal tube, made of flexible plastic, in the right hand and starts inserting it through the mouth opening. g) The tube is inserted through the cords to the point that the cuff rests just below the cords h) Finally, the cuff is inflated to provide a minimal leak when the bag is squeezed Using a stethoscope , listens for breathing sounds to ensure correct placement of the tube
- 38. Straight blade technique Follow the steps outlined for curved blade technique, but advance the blade down the hypopharynx, and lift the epiglottis with the tip of the blade to expose the vocal cords. The tip of the laryngoscope blade fits below the epiglottis, which is no longer visible with the blade in position.
- 39. Intubation - Trouble-shooting Can’t see the cords Look for landmarks Control the tongue BURP maneuver if epiglottis seen Another attempt needed (limit number) Reposition Change something (blade, tube) Avoid hypoxia
- 40. Confirmation of ETTPlacement Seeing tube go through cords Clinical Confirmation Water vapor seen inside tube O2 Saturation Chest rise Equal breath sounds No sounds over epigastrium CO2 Detection / Esophageal Detector Devices Chest X-ray NO single technique is 100% reliable
- 41. Rescue Devices LMAs (laryngeal mask airway) I-LMAs (intubating LMA) Combitube Bougie Pick one or two and practice Need to be comfortable before crisis
- 42. LMA Usedin any age Easy to place Few complications Contraindications: Gag reflex FBs Airway obstruction High ventilation pressure Does not secure airway
- 43. Laryngeal Masks Indications: When endotracheal intubation is not necessary or it’s difficult Contraindications: • Non-fasted patients • Morbidly obese patients • Obstructive or abnormal lesions of the oropharynx Air entry is confirmed by listening for air entry into the lungs with a stethoscope
- 44. The cuff ofthe mask is deflated before insertion and lubricated. 1.The patient is sedated or fully anaesthetized if conscious, and their neck is extended &mouth opened widely. 2.The apex of the mask, with its open end pointing downwards toward the tongue, is pushed backwards towards the uvula.
- 45. 3.The cuff followsthe natural bend of the oropharynx, and its long walls come to rest over the piriform fossa. 4.Once placed, the cuff around the mask is inflated with air to create a tight seal.
- 46. Laryngeal Mask Highersuccess rate Does NOT protect from aspiration Difficult to maintain during transport
- 47. Advantages vs. Disadvantages Advantages: •Allows rapid access •Does not require laryngoscope •Relaxants not needed •Provides airway for spontaneous or controlled ventilation •Tolerated at lighter anesthetic planes Disadvantages: • Does not fully protect against aspiration in the non-fasted patient • Requires re-sterilization
- 48. LMA Sizing LLMMAASSiizzee PPaattiieenntt SSiizzee 11 NNeeoonnaattee // IInnffaannttss << 55 kkgg 11 ½ IInnffaannttss 55--1100 kkgg 22 IInnffaannttss // CChhiillddrreenn 1100--2200 kkgg 22 ½ CChhiillddrreenn 2200--3300 kkgg 33 CChhiillddrreenn//SSmmaallll aadduullttss 3300--5500 kkgg 44 AAdduullttss 5500--7700 kkgg 55 LLaarrggee aadduulltt >>7700 kkgg
- 50. Combitube Twosizes Small (4 to 5.5 feet tall) Regular (over 5.5 feet tall) Not useful in most kids Easy to place Contraindications Gag reflex Esophageal disease Caustic ingestions FBs/Airway obstruction
- 51. Other Toys Lighted stylet Flexible fiberoptic scopes Rigid fiberoptic scopes Bullard Shikani Video laryngoscopy
- 52. Rules “To avoidtrouble one must be prepared for trouble” “Have an IV access & experienced assistant” “Do what you masters” “Have definitive plan A, but have plan B & C”
- 53. Rules “Use yourcommon sense” “ Do not continue to do the same thing and expect different results’’ “Easier comes first” “Each difficult intubation is a different”
- 54.
Editor's Notes
- #3 Low flow-nasal canula/partial ,non rebreather and venturi
- #4 humidification, warming, and occasionally filtration ,FRACTION OF INSPIRED O2- Natural air includes 20.9% oxygen, which is equivalent to FiO2 of 0.21.
- #6 35-55%o2@6-10l/min
- #8 Partial rebreather-deliver 60%o2////////non rebreathing-100%o2 delivery
- #11 Tip of the mouth to corner of mandible,INDICATION –ALTERED MENTAL STATUS ….GAG REFLUX SHOULD BE ABSENT…PROCEDURE ..TONGUE GASPED BY THUMB & PROTUDED FORDWARD ,,THEN OPA INSERTED WITH CONCAVITY UPWARDS TILL RESISTENCE IS FELT ..THEN SIMULTANEOUSLY INSERTION & ROTATION OF 180 DEGREE PERFORMED
- #15 Nostril to tragus…less contact with tongue ,less chances of inducing emesis,tolerated by conscious patients..ind-macroglosia,tonsil hypertrophy,upper air way obstruction
- #24 CP obliterated the esophageal lumen at the level of the 5th cervical vertebra,prevents regurgitation
- #32 Suction,o2,airway equip,position,monitors,etco2