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Pediatric airway management shapiro


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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>