2012 airway management

Airway
Management

Pediatrics

Overview
•REFLECTION •Advanced airway
management
•Pediatric airway
anatomy & physiology •PRACTICE

•O2 delivery devices •Rapid sequence
intubation (RSI)
•Basic airway
management •The Difficult Airway

•PRACTICE •PRACTICE

Page 1
Pediatrics xxx00.#####.ppt 7/10/2012 8:23:12 AM

Pediatric Airway
Anatomy &
Physiology

Pediatrics

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

Page 3

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

Page 4

Pediatric vs. Adult Airway

Page 5


•Conical larynx
•Narrowest point @ cricoid
ring

•Larger occiput

•Compliant and distensible
large airways

Page 6

•Larger adenoidal tissues

•Narrower tracheal diameter and shorter tracheal
length

•Narrower larger airways

Page 7

So what is the relevance?

Larynx more superior and anterior •Shortens thyromental distance
•“Bunching” of the tongue in the
oropharynx
•More acute angle between
tracheal opening & epiglottis
Relatively large tongue •Difficult to move out of the way
Large, floppy epiglottis •Can cause obstruction
•Influences choice of
laryngoscope blade
Conical larynx •Narrowest point is cricoid
•Influences ETT size

Page 8

So what is the relevance?

Large occiput •Obstructs airway
•Influences patient positioning
Compliant & distensible large •Susceptible to collapse &
airways obstruction
Narrower tracheal diameter, •Alters airway resistance
large airways & shorter tracheal •Can influence WOB
length
Larger adenoidal/tonsillar •Can cause obstruction
tissue •Susceptible to bleeding

Page 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
Page 11

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
Page 12

Oxygen Delivery
Devices &
Basic Airway
Management

Pediatrics

Objectives
‐Decide which O2 delivery device would be most appropriate
given a case-based example
‐Recall at least:
•5 complications associated with the use of airway
adjuncts
•3 complications associated with BVM
‐Practice the placement of airway adjuncts using an airway
task trainer
‐Perform proper bag-valve mask ventilation using an airway
task trainer

Page 14

Oxygen delivery devices
•Nasal Cannula •Non rebreather mask

•Heated high flow Nasal •Cpap/Bipap
Cannula
•Tent/hoods
•Simple Face mask
•Bag mask
•Venturi mask

Page 15

•Nasal Cannula
‐ up to 4 lpm (adults 6 lpm)
‐Approximately 24-45% Fio2

Page 16

Heated High Flow Nasal Cannula

•Uses Optimal heated humidified O2

•Higher flow which causes a

“splinting” effect to the airways

•Reduces WOB

•Flow rates exceed patients

inspiratory flow rate

Page 17

Heated High Flow Nasal Cannula
•Infant/ Pediatric cannula
‐up to 8 lpm

•Adult Cannula
‐ 10 to 60 lpm

Page 18

Simple Face Mask
•Flow Rates 6-10 lpm

•Approximately 35%-55%

Page 19

Venturi Masks
•Allow for a set O2 concentration

•Entrain Room Air

•Liter flow depends on

Set Fio2

•Can deliver up to 100%

Page 20

Non rebreather mask
•Has a one way valve

•Can deliver close to 100% Fio2

•Liter flow enough to keep the

bag inflated

Page 21

Bipap/Cpap
•BiPAP- delivers a higher pressure on inspiration,
helping the patient obtain a full breath, and a low
pressure on expiration, allowing the patient to exhale
easily.

•CPAP-delivers a steady pressure of air, which assists the
patient's inspiration (breathing in) and resists expiration
(breathing out).

Page 22

Bag/Mask
•Used to ventilate

•Delivers 100% Fio2

•Describe technique for
bagging

Page 24

Intro to Ambu Bag

Page 26

Positioning and opening the airway

Page 28

Oropharyngeal Airway
•Prevents upper airway obstruction

•May be used as a bite block

•May make Bag-valve-mask ventilation more effective

•Should not be used in semi comatose of alert patients

Page 29

Complications of Oropharyngeal Airways
•Vomiting and aspiration

•Obstruction can occur if the tube is to Large or to small

•Dental damage

•Oral damage

•Laryngospasm

Page 30

Oropharyngeal Airway

Page 31

Nasopharyngeal Airway
•May be used to bypass an upper airway obstruction

•Reduce trauma caused by nasotracheal suctioning

•To determine proper size measure from the tip of the
nose to the tragus of the ear plus 2 cm.

Page 32

Complications of Nasopharyngeal
Airways
•Laryngospasm and coughing (too long)

•Nosebleeds

•Do not use of patients undergoing anticoagulation
therapy.

•Sinus infection

Page 33

Nasopharyngeal Airway

Page 34

What would you do???
•Intervention

•Why

•Liter flow

Page 36

•14 y/o male with end-stage CF and recent sinus surgery
is admitted to your service. His blood gas is as followed
pH 7.35 Pco2 60 Pao2 85, HCO3 26

Vital signs O2 sat 88%, RR 30 HR 95 BP 130/90

What would you do?

Page 37

•16 year old soccer player is admitted to the ICU,
following an acute onset of SOB after a coughing spell.
His recent chest x-ray shows a moderate right sided
pneumothorax. Pt is hemodynamically stable.

•What would you recommend?

Page 38

•A 6 month old RSV+ is admitted to the ICU with
increase WOB. His vital signs are as followed

HR 180 RR 80 Sat 90

What would you recommend?

Page 39

Advanced Airway
Management:
Orotracheal
Intubation

Pediatrics

Objectives
‐Identify 5 laryngeal anatomic landmarks seen during
laryngoscopy
‐Recall at least 3 indications and 5 complications associated
with orotracheal intubation
‐Choose the appropriate sized ETT and laryngoscopy blade
according to the patient‟s age/weight
‐Decide on an appropriate combination and dosage of
medications required for intubation
‐Carry out the proper sequence of events involved in tracheal
intubation

Page 41

General Anatomic Overview
Anatomical Pop Quiz
EPIGLOTTIS

ARYEPIGLOTTIC FOLD

CUNEIFORM TUBERCLE
INTERARYTENOID ARCH
CORNICULATE TUBERCLE

Page 42

Anatomical Pop Quiz
INNERVATION
•Sensation
‐Supraglottic
‐Infraglottic

•Motor
‐Exception

Page 43

1st Commandment

Page 44

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

Page 45

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 (highly arch palate increases difficulty)

Page 46

Examination of the oropharynx
•Mallampati Classification: degree of airway
difficulty based on ability to visualize
‐Soft palate
‐Faucial pillars
‐Uvula.

Page 47

Range of motion at the AO joint

•Reduced ROM does not
allow alignment of airway
axes

Page 48

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

Page 49

Indications
•Actual or anticipated compromise in airway
patency, ventilation and/or oxygenation

•Altered mentation/Compromised airway reflexes

•Airway or parenchymal lung disease

•Hemodynamic compromise

•Cardiopulmonary arrest

•Neuromuscular weakness

Page 50

Equipment/Preparation
•Monitors •ETT, stylet and syringe

•Gloves •Laryngoscope and blade

•Suctioning equipment •Tape/tube holder
‐Test suction •Obtain/verify IV access
‐Ensure within reach •Medications
•CO2 detector

Page 51

Ready…
•Positioning

•Preoxygenate

•Suction

Set…
•Check vitals

•Administer medications

Page 52

Intubate!
•Insert laryngoscope blade

•Displace tongue

•Position blade tip

•Lift

•Insert ETT/Remove stylet

•Inflate cuff

Page 53

Confirmation
•Condensation in ETT

•CO2 detector

•Auscultation

•CXR

Secure ETT

Page 54

Complications
•Physiologic
‐Vomiting/Aspiration

‐Cardiovascular instability/arrest

•Malposition
‐Esophageal intubation

‐Mainstem bronchus intubation

•Traumatic
‐Airway trauma

Page 55

Rapid Sequence
Intubation
Slides courtesy of Dr. Fong Lam

Pediatrics

Objectives
‐Assess the need for Rapid Sequence Intubation (RSI) given
case-based examples
‐Summarize the steps for RSI using case-based examples

Page 64

What is Rapid Sequence Intubation
(RSI)?
•Intubating quickly

•Intubating efficiently

•Intubating without bag-mask ventilation
‐ AVOID bag-mask ventilation

•BUT… do what you have to do. If you can‟t intubate,
then bag-mask ventilate

Page 65

When Should I Use RSI?
•Any acute/sudden respiratory decompensation
‐Acute traumas
‐Code Reds

•When risk of aspiration of gastric contents is high

Page 66

How Do I Perform RSI?
•Prepare

•Preoxygenate

•Premedicate

•Paralyze

•Place ETT

Page 67

Prepare
•Let the RN and RT know that RSI will be done
‐ That way, they are also ready
‐ Minimize bag-mask ventilation
‐ Cricoid pressure AFTER sedation, although care should be taken to
avoid deforming/moving the airway from view
‐ Once medications are given, give in succession as quickly as possible

•Talk to the patient, if possible
‐ Spontaneously ventilating, even minimally will help prior to induction

•Get in the best position possible
‐ Stand at head of bed & position the patient
‐ Get all equipment ready

Page 68

Preoxygenate
•Supply 100% oxygen at the highest flow rate
‐Goal is to fill FRC
‐~3-5 minutes, if possible
‐Avoid BMV, if possible
‐This allows for longer apnea time prior to desaturation
‐Patient will still become hypercarbic

Page 69

Premedicate
•Atropine (0.02 mg/kg IV)
‐Blunt vagal effects of laryngoscopy (especially in infants)
‐Dries secretions

•Lidocaine (1mg/kg IV)
‐Blunts ICP spike from laryngoscopy

Page 70

Premedication
•Midazolam (0.1-0.2 mg/kg IV/IM/IN)
‐Hemodynamically neutral

•Fentanyl (2-4 mcg/kg IV)
‐Beware of rigid chest when infused quickly
‐Hemodynamically neutral

•Ketamine (1-3 mg/kg IV)
‐Raises BP and HR
‐Useful if hypotensive or with asthma
‐Avoid in head trauma/increased ICP/IOP

Page 71

Premedicate
•Thiopental (3-5 mg/kg IV)
‐Negative inotrope
‐Decreases CMR & CBF  ICP

•Etomidate (0.25 mg/kg IV)
‐Causes adrenal suppression
‐Avoid in septic shock, if possible

Page 72

Paralyze
• Rocuronium (1.2-1.5 mg/kg IV)
‐ Onset ~60-90 seconds
‐ Duration ~30-45 minutes
OR

• Vecuronium (0.15-0.2 mg/kg IV)
‐ Onset ~3-5 minutes
OR

• Succinylcholine (1-2 mg/kg IV)
‐ Causes bradycardia with rapid injection in infants
‐ Avoid in burns, crush, neuromuscular disease, renal failure
‐ Causes hyperkalemia due to fasciculations
‐ Onset ~30-60 seconds

Page 73

Place ETT
•Use cricoid pressure, if possible
‐Some helpers get overanxious and give too much pressure
‐It may be useful for you to find the best location and then
have someone hold the position

•Place the tube

•Be prepared for difficult airways!!!

Page 74

REMEMBER:
•Prepare
‐ Good communication

•Preoxygenate
‐ Avoid bag-mask ventilation

•Premedicate
‐ Based on the disease

•Paralyze
‐ Safer to use non-depolarizing if history unknown

•Place ETT
‐ Be prepared for difficult airways

Page 75

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??

Page 76

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)

Page 77

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.

‐Why?
‐What medications would you NOT give?
‐Requires RSI??

Page 78

Premedication (alternative/sepsis)
•+/- Atropine (0.02 mg/kg IV)

•Ketamine (1-3 mg/kg IV)

•Rocuronium (1.2-1.5 mg/kg IV)

Page 79

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.

‐Why?
‐What medications would you NOT give?
‐Requires RSI??

Page 80

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

Page 81

The
Difficult Airway

Pediatrics

Objectives
‐Be aware of the institutional protocol for a “Known/Suspected
Critical Airway”
‐List at least 3 complications associated with LMA insertion
‐Choose the appropriate sized LMA according to the patient‟s
weight
‐Practice the placement of LMA „s using an airway task trainer

Page 83

1st Commandment

Page 84

2nd Commandment

The intubator should always have a
second strategy to provide
oxygenation and ventilation if the
initial airway approach fails.

Page 86

Remember…

Anticipate
&
Plan

Page 87

Laryngeal Mask Airway
•Supraglottic device •Indications:
‐ Failed BVM or endotracheal
•Easy to insert intubation

•Low complication rate •Contraindications:
‐ Awake patients or patients
‐Malpositioning
with a gag reflex
‐Increased insertion difficulty ‐ Those requiring high
‐Laryngosapsm pressures to ventilate

‐Bronchospasm

Page 88

Laryngeal Mask Airway

•It is important to choose the
correct size
‐ Too large  will be difficult to
place
‐ Too small  will not maitain
an adequate sea

**Combined width of index/middle/ring fingers can be used to estimate size

Page 90

2012 airway management

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