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Cr pediatrics residents airway management part 2


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Cr pediatrics residents airway management part 2

  1. 1. Airway Management Carlos Rodriguez, MD Assistant Professor Department of Pediatric Anesthesiology
  2. 2. Evaluation of the Airway Size of upper incisors Relation of the maxillary and mandibular incisors at mouth closure and with voluntary protrusion of lower jaw Interincisor distance Visibility of the uvula Shape of the palate Thyromental distance Hyomental distance Length of neck Range of motion in the neck and head
  3. 3. Mallampati Classification Classification developed to grade the size of the tongue in relation to the size of the oral cavity Phonation FALSELY improves the view Class I: soft palate, tonsillar pillars, uvula Class II: tonsillar pillars and base of uvula Class III: soft palate Class IV: hard palate
  4. 4. Mallampati Classification
  5. 5. Positioning for Endotracheal Intubation Sniffing Position  Elevation and extension of the patient’s head  Goal is to align the oral, pharyngeal, and laryngeal axes  May not be appropriate for younger patients Patient’s face should be near the practitioner’s xyphoid cartilage Shoulder roll or ramp may be indicated External auditory meatus/sternal notch alignment
  6. 6. Bag Mask Ventilation Critical component of airway management Provides oxygenation and ventilation before the placement of an airway Create a SEAL!!!!!!  Use the thumb and index finger to hold the mask to the face  Other fingers hold the mandible Use jaw thrust to relieve obstruction Look for chest rise and fog within mask One-person vs Two-person ventilation technique
  7. 7. Bag Mask Ventilation Large occiput in the pediatric population leads to flexion of the neck in the supine position Children have relatively larger tongues Leads to obstruction and possibility of difficulty in ventilation
  8. 8. Airway Adjuncts Oral Airway  Relieves obstruction created by tongue/epiglottis  Poorly tolerated in lightly anesthetized patients  Risk of damage to soft and hard palate Nasal Airway  Useful in patients after oral surgery  Better tolerated in awake patients/less likely to gag  Risk of epistaxis  Contraindicated in patients with basilar skull fractures and coagulopathies
  9. 9. Endotracheal Intubation Laryngoscope  Held with the left hand  Blade is inserted into the right side of the mouth  Blade deflects the tongue to the left  Avoid pressure on gums and teeth  USE forward and upward movement  AVOID lever movement towards practitioner
  10. 10. Endotracheal Intubation  Miller Blade/Straight Blade  The blade passes the epiglottis  Elevation of the epiglottis exposes the glottic opening
  11. 11. Endotracheal Intubation  Macintosh/Curved Blade  The blade is advanced into the vallecula  Forward and upward movement moves epiglottis to reveal glottic opening
  12. 12. Endotracheal Intubation Tube size is determined according to internal diameter Lengthwise centimeter markings will guide practitioner of depth placement Cuff vs No cuff  Cuffs facilitate positive pressure ventilation and help prevent the aspiration of gastric contents Appropriate size of tube:  4 + Age/4 = tube diameter Estimate endotracheal length:  12 + Age/2 = length of tube (in cm)
  13. 13. Endotracheal Intubation Confirmation of Tube Placement  Clinical Assessment  Auscultationof lung fields and over stomach  Symmetric bilateral movement of chest  Condensation within the endotracheal tube  Monitors  End-TidalCO2  Pulse Oximetry
  14. 14. Endotracheal Intubation  Glottic Opening  Grade I: full view  Grade II: posterior portion visualized  Grade III: Only the tip of the epiglottis is visible  Grade IV: Only soft palate is visible
  15. 15. LMA
  16. 16. Pediatric/Infant Anatomy Large and floppy epiglottis  May lie against the posterior wall of the pharynx Large tongue relative to the mandible Glottis lies higher and more anterior Vocal cords are angled more forwards and downwards
  17. 17. LMA: Indications Routine Airway Management  “as long as there is not a contraindication to the use of the face mask” Difficult Airway Management  Emergency Airway  Conduit for Intubation
  18. 18. LMA: Contraindications Do NOT use as a substitute when the airway MUST be guaranteed Reduced pulmonary compliance Patients with certain oral and periglottic pathology Situations when airway cannot be readily accessed when dislodged Full stomach  Nonfasted persons  Morbidly obese  Recent trauma  GERD  Intestinal obstruction
  19. 19. LMA How do we determine the size of LMA a patient will need?
  20. 20. LMA SizesSize Weight1 < 5 kg1.5 5-10 kg2 10-20 kg2.5 20-30 kg3 30-50 kg4 50-70 kg5 > 70 kg
  21. 21. Position Distal tip above the esophageal sphincter Proximal aspect of the mask juxtaposed with the base of the tongue Sides of the mask facing the pyriform fossae Inflated cuff creates a low-pressure seal around the periphery of the laryngeal inlet
  22. 22. What is the optimal CuffPressure? Recurrent laryngeal nerve injury Distorted pharyngeal anatomy- reduced mucosal perfusion Postop stridor Sore throat and dysphagia Manufacturers recommend pressures lower that 60 cmH2O
  23. 23. 40 cmH2O Schloss, et all- 2012 >40cmH2O Sore throat Less efficient ventilation <40cmH2O Lower pressures lead to a better seal- better to conform to the surrounding hypopharynx Small inflation volumes can lead to substantial increases in intracuff pressures
  24. 24. Laryngeal Mask Airway Alternative to tracheal intubation Difficult Airway Algorithm Placed blindly; cuff is deflated with opening facing tongue Does not reliably prevent aspiration of gastric contents;
  25. 25. Anesthesiology 2003; 98:1269 –77
  26. 26. The Difficult Airway Algorithm originated in 1993 LMA added to algorithm in 2003 Definition: “conventionally trained anesthesiologist experiences difficulty with intubation, mask ventilation or both”
  27. 27. The Difficult Airway Disorders with Associated Airway Problems  Achondroplasia  Arthrogryposis  Beckwith-Wiedemann syndrome  Cornelia de Lange syndrome  Epidermolysis Bullosa  Goldenhaar syndrome  Pierre-Robin syndrome
  28. 28. The Difficult Airway Disorders with Associated Airway Problems  Treacher Collins syndrome  Trisomy 21  Turner syndrome  Mucopolysaccharidoses  Hunter  Hurler
  29. 29. The Difficult Airway
  30. 30. The Difficult Airway Achondroplasia  Midfacialhypoplasia  Small nasal passages  Small mouth  Megacephaly  Difficult mask  Difficult intubation
  31. 31. The Difficult Airway Arthrogryposis  Hypoplastic mandible  Cleft palate  Torticollis  Difficult intubation
  32. 32. The Difficult Airway  Beckwith- Widermann syndrome  Macroglossia (smaller with age)  Difficult intubation
  33. 33. The Difficult Airway Cornelia de Lange syndrome High arch palate Micrognathia Large tongue Cleft palate Short neck Difficult intubation
  34. 34. The Difficult Airway  Epidermolysis Bullosa  Pressure lesions in mouth and airway  Possible microstomia  Postoperative laryngeal obstruction due to bulla  Difficult intubation
  35. 35. The Difficult Airway
  36. 36. The Difficult Airway Goldenhaar syndrome  Hypoplastic zygomatic arch  +/- cleft tongue, palate  T-E fistula  Macrostomia  Mandibular hypoplasia  Cervical spine defects  Difficult intubation
  37. 37. The Difficult Airway  Pierre-Robin syndrome  Hypoplastic mandible  Pseudo-macroglossia  High arched palate  Difficult intubation
  38. 38. The Difficult Airway
  39. 39. The Difficult Airway Treacher Collins syndrome  Malar, mandibular hypoplasia  Cleft lip  Choanal atresia  Macro or microstomia  Difficult intubation  Difficult ventilation
  40. 40. The Difficult Airway  Trisomy 21  Small mouth  Hypoplastic mandible  Protruding tongue  C1-C2 instability  Possible difficult intubation and ventilation
  41. 41. The Difficult Airway Turner syndrome  Narrow maxilla  Small mandible  Short neck  Difficult intubation
  42. 42. The Difficult Airway  Mucopolysaccharidoses  Hurler  Coarse facial features  Macroglossia  Short neck  Tonsillar hypertrophy  Narrowing of airways  Difficult intubation