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PEDIATRIC AIRWAY MANAGEMENT presentation
- 1. PEDIATRIC AIRWAY MANAGEMENT MODERATOR –DR AMAN PRESENTER – DR GAURAV
- 2. ANATOMY HEAD Large headsize and short neck (child < 2 years). Obligate nasal breathers with poor tolerance to obstruction Anaesthetic Implications- Neck flexion in supine position can cause airway obstruction. Use a shoulder roll for neck extension and proper positioning. Aim to bring tragus and manubrium sterni in one plane
- 3. Tongue Small mouth,large tongue Difficult to visualize larynx Anaesthetic Implications- Likelihood of upper airway obstruction Use an oro/nasopharyngeal airway to maintain airway patency
- 4. Larynx High, anteriorlyplaced larynx C2 in infants, C3/4 in children compared to adult (c4-c5) Anaesthetic Implications- More acute angle between oral and laryngeal axes Difficult in nasal intubation where ETT can dislodge in anterior commissure rather than trachea
- 5. Epiglottis Leaf like,hanging epiglottis which is difficult to lift and glottic opening is difficult to visualize Infant epiglottis are omega shaped and axis away from trachea Large tonsil and adenoids Anaesthetic Implications- Choose an appropriate laryngeal blade (Miller blade) to directly lift the epiglottis Likelihood of upper airway obstruction and bleeding during oral/nasal intubation Gentle laryngoscopy and ETT insertion
- 6. Trachea Short andnarrow trachea, funnel shaped Increase resistance with airway edema or infection Collapse easily with neck hyperflexion or extension Anaesthetic Implications- Chances of unilateral lung ventilation or accidental extubation are higher High airway resistance after inflammation making them prone to hypoxia Check for bilateral ventilation of lungs after ETT fixation
- 7. Cricoid Narrowest portionof airway in infants elliptical shape lies atC4 at birth (C6 in adults) Acts as cuff during tracheal intubation Anaesthetic Implications- Increase resistance with airway edema or infection Tight ETT can cause mucosal ischemia and post intubation stridor
- 8. Neck Short thickneck makes localization of cricothyroid membrane difficult Anaesthetic Implications- Cricothyroidotomy difficult in children aged < 8 years. Higher risk of puncture of posterior tracheal wall Pre-define and mark the landmarks if a difficult airway is anticipated. Surgical tracheotomy preferred over scalpel technique in a ‘can’t intubate can’t ventilate’ (CICV) scenario in children aged <8 years
- 9. Chest wall Horizontalribs More A-P diameter Increase compliance due to weak rib cage Diaphragmatic breathing Anaesthetic Implications- FRC determined solely by elastic recoil of lungs Chest wall collapse with negative pressure
- 10. Key differencecompared to adult airway Larger occiput Nasal breathers Large tongue Epiglottis is floppier Anterior and cephaloid larynx Funnel shaped trachea Cricoid cartilage is narrowest
- 11. PHYSIOLOGY High metabolicrate (5-8 ml/kg/min) Oxygen consumption of infant (6ml/kg/min) is twice that of adult (3ml/kg/min). Tidal volume is relatively fixed (6-7ml/kg/min) Minute ventilation is more dependent on raspiratory rate than tidal volume Lung compliance is less while chest compliance is more than adult. Lack of type 1 muscle fibers Higher vagal tone Rib cage is more horizontal
- 12. Anaesthetic Implications- Higher O2 consumption and less apnoea time to desaturation After induction of anaesthesia, loss of FRC causes atelectasis and rapid desaturation Prone to early fatigue adding to early desaturation Restricted deep breathing More chances of bradycardia during airway instrumentation. Bradycardia leading to low cardiac output further aggravating hypoxemia Hypoxia itself causes bradycardia
- 13. Airway assessment Lookfrom afar- Is the chest moving ? Can you hear the breath sounds ? Are there any abnormal airway sounds (stridor, snoring) ? Is there increased respiratory effort with no airway or breath sounds ?
- 14. Medical History URTI– laryngospasm , bronchospasm, desaturation during anaesthesia Snoring – adenoid hypertrophy, OSA, upper airway obstruction Chronic cough – subglottic stenosis, tracheoesophageal fistula. Productive cough – pneumonia, bronchitis. Sudden onset of new cough – foreign body aspiration. Inspiratory stridor – macroglossia, laryngeal web, laryngomalacia, extra thoracic foreign body. Hoarse voice – laryngitis, vocal cord palsy, papillomatosis Asthma – bronchospasm
- 15. Medical History Repeatedpneumonia – GERD, bronchiectasis, tracheoesophageal fistula, congenital heart disease Atopy , allergy – increase airway reactivity Congenital syndromes – Pierre Robin syndrome, Treacher Collins, Klippel Feil, Down syndrome etc. Previous anaesthetic problem Environmental smokers
- 16. Physical Examination Facialexpressions Nasal flaring Mouth breathing Colour of mucous membrane Respiratory rate chest retractions Change in voice Mouth opening and size of mouth Mallampati score
- 17. Physical Examination Looseor missing teeth Size and configuration of mandible and palate Inspiratory and expiratory stridor (foreign body , vascular ring ) Prolonged expiration ( lower airway disease) Baseline oxygen saturation
- 18. Airway Management Airwaypatency improved on – Suction nose and oropharynx Reposition child Head tilt, chin lift ,jaw thrust Use airway adjunct (NPA, OPA) Bag and mask ventilation Intubation
- 19. Requirement for airwaycart for a child (SOAPME) Suction -Working, effective suction and appropriate size suction catheter. Oxygen -Oxygen source, tubing, flow meters. Airway Devices -Appropriate sizes of face masks, self-inflating bag, oropharyngeal and nasopharyngeal airways, laryngoscope blades (MacIntosh: 1, Miller: 0,1,2) video laryngoscope, supraglottic airway (SGA, 1st and 2nd generation), ETT, intubating stylet, tube exchanger, FOB. Positioning -“Sniffing” position, shoulder roll for smaller children. Pharmacy -IV anaesthetics, muscle relaxants. Resuscitation drugs: adrenaline, flumazenil. Monitors -SpO2, ECG, NIBP, EtCO2, RR, temperature. Equipment -Defibrillator, cricothyroidotomy, tracheostomy sets for emergency front of neck access (FONA)
- 21. SUCTIONING Measure length– patients ear lobe to tip of the nose Duration - <10 sec May result hypoxia, decrease in heart rate, bronchospasm , laryngospasm. Appropriate suction catheter size Neonates 5-6 Fr Infants 6-8 Fr Child 10 Fr Age Pressure (mmhg) <1 yr 60-80 1-12 yr 80-120 13-17 yr 100-150
- 22. Artificial airway Oralairway Nasal airway Appropriate size is the key Too small – will not adequately displace the tongue Too large – may obstruct larynx or interfere with mask fit
- 23. Choosing Correct Size Oral airway – Place OPA against side of the face , with flang at the corner of the mouth the tip should reach angle of the jaw.
- 24. Choosing Correct Size Nasal airway- Distance from nares to angle of mandible approximates the proper length NPA sizes from 12fr to 36Fr. Shortened endotracheal tube is used Avoid in case of adenoid hypertrophy –bleeding and trauma
- 25. Bag and maskventilation Clear plastic mask with inflatable rim provides atraumatic seal. Proper area for mask application- bridge of nose extend to chin. Maintain airway pressure < 20cm H2O.
- 26. Bag and maskventilation Place fingers on mandible to avoid compressing pharyngeal space. Had on ventilation bag at all times to monitor effectiveness of spontaneous breaths. Continuous positive pressure when needed to maintain airway patency.
- 27. Bagging unit Neonate– 250- 500 ml Infant – 500ml Paediatric bag – 500-1000ml Small adult – 1L Adult bag – 1.5 – 2 L
- 28. Patient Position Aneutral “sniffing” position without hyperextension is appropriate for infants and toddlers. Avoid extreme hyperextension in infants as it may cause airway obstruction In patients with head or neck injuries, maintain the neck in a neutral position.
- 29. Laryngoscopy Goals Clearview of laryngeal inlet Minimize stimulation Gentle handling of epiglottis Short duration of attempt Choose correct laryngeal blade and ETT size
- 30. LARYNGOSCOPE BLADES INCHILDREN Blade Types and Usage : Straight Blades (e.g., Miller, Wisconsin) Placed under the epiglottis to lift it directly and expose the vocal cords. Curved Blades (e.g., Macintosh): Placed in the vallecula, lifting the epiglottis indirectly to expose the cords.
- 31. Blades :Miller vsMacintosh Feature Miller Blade Macintosh Blade Preferred Age Group Infants and younger children Older children Epiglottis Management Lifts epiglottis directly Lifts indirectly via vallecula Visualization Better in anterior larynx (common in infants) Less effective in very young airway Precaution Avoid pressure on teeth/gums Less traumatic due to curvature
- 32. Blade size Age Bladesize Infant Miller 1 2-5 year Miller 1-2 6-10 year Miller 2 > 10 year or adolescent Miller 2-3
- 33. Endotracheal tubes Forneonates ET tube size roughly corresponds to1/10th of gestational age rounded down to nearest size. e.g – 36 weeks would get 3.5 ETT. Age ETT size (ID) (mm) ETT length (cm) <6 months 3-3.5 10 6-1 year 3.5-4.0 11 1-2 year 4-5 12
- 34. 2-12 years– Size : Uncuffed ET tube : (age in years / 4)+4 Cuffed ET tube : ( age in years / 4) + 3.5 Length : (age in years / 2) + 12
- 35. Cuffed V/S Uncuffedtube Uncuffed ETT Recommended: In children < 8 years to avoid: Post-extubation stridor Subglottic stenosis Cuffed ETT Preferable When: High risk of aspiration(e.g., bowel obstruction) Low lung compliance(e.g., ARDS, pneumoperitoneum, CO insufflation of ₂ thorax, CABG) Need precise control of ventilation & pCO (e.g., ↑ intracranial pressure, single ₂ ventricle physiology)
- 36. Cuffed V/S Uncuffedtube Disadvantages of Cuffed ETT: Smaller size = ↑ airway resistance ↑ Work of breathing Poorly paediatric design Need to keep Cuff pressure must be < 25 cm H O ₂ Disadvantages of Uncuffed ETT: Frequent tube changes in long-term use Aesthetic gas leak into environment Needs higher fresh gas flow (> 2 L/min) ↑ Aspiration risk
- 37. Micro-cuff ETT Microthin polyurethane cuff. Low pressure seal. Reduces micro aspiration Lower risk of tracheal trauma Improved vocal cord visualisation.
- 38. Acute deterioration postintubation Displaced ETT : ETT may be in trachea or in right or left main bronchus. Obstruction of ETT : secretions, blood, pus, foreign body, kinked ETT. Pneumothorax : simple , tension. Equipment failure : disconnection of O2 source, leaks in vent circuits, loss of power or vent malfunction.
- 39. PREDICTORS OF DIFFICULTAIRWAY LEMON Look : short neck , large tongue, micrognathia Evaluate : 3-3-2 3 fingers breadth of mouth opening 3 fingers breadth submental to hyoid 2 fingers breadth hyoid to thyroid Mallampati score Obstruction Neck mobility
- 40. Difficult airway management techniques OPTIMAL EXTERNAL LARYNGEAL MANIPULATION : Helpful for infants and children with immobile or shortened necks. Either by assistant or laryngoscopist.
- 41. Laryngeal Mask Supraglotticairway device developed by Dr Archie Brain Useful in difficult airway situations. Easy to place Used in any age Contraindication : Gag reflex Foreign body Airway obstruction High ventilation pressure Disadvantage : laryngospasm, aspiration.
- 43.
- 44. Stylet Stylets arelong, thin bendable rods Inserted into the ETT prior to intubation and curved into a hockey stick shape to facilitate intubation Stylet should reaches the tip of the tube but does not protrude out. If it does not reach the tip of the tube the tube will bend during intubation If it sticks out it will cause trauma to the glottis, vocal cords and tracheal mucosa
- 45. Bougies A bougieis a straight, semi-rigid stylet-like device with a preformed curved tip used to facilitate intubation. The bougie may be introduced between the vocal cords, while maintaining the laryngoscope and bougie in position, an assistant may thread the ETT over the bougie into the trachea
- 46. Fibreoptic laryngo /bronchoscope Fiberoptic system that transmits the image from the tip of the instrument to an eyepiece or a video camera at the proximal end. Tip can be manipulated to navigate the instrument around corners.
- 47. Rigid bronchoscope Alsoventilating bronchoscopes, having a side port for connection to the anesthesia circuit. They may be used for diagnostic purposes but are most commonly used for retrieving foreign objects.
- 48. Video laryngoscope Themost commonly available video laryngoscopes for use in children are: Airtraq optical laryngoscope, Glidescope (Verathan Medical), CMac (Karl Storz), Truview (Truphatek) and Pentax AWS (Pentax).
- 51. Critical Airway Can’tventilate Can’t intubate LMA contraindication All intervention failed
- 52. Cricothyroidotomy <5 yearsof age : Needle cricothyroidotomy and bag ventilation 5-10 years of age : Needle cricothyroidotomy and bag ventilation If oxygen saturation inadequate, transtracheal jet ventilation >10 years of age : Needle cricothyroidotomy with TTJV Surgical cricothyroidotomy – contraindicated <10 years of age
- 53. Needle cricothyroidotomy Insertionof catheter through cricothyroid membrane Temporarily recures airway