intraop management in children

1. PRESENTER : DR SNIGDHA
MODERATOR : DR AJIT KUMAR
INTRA OPERATIVE MANAGEMENT IN PEDIATRIC
AGE GROUP: AIRWAY MANAGEMENT AND
EVALUATION, INDUCTION, VENTILATORY
STRATEGIES, MAINTENANCE, EXTUBATION

2. OVERVIEW
1. ANATOMY
2. PHYSIOLOGY
3. AIRWAY ASSESSMENT
4. AIRWAY MANAGEMENT
5. DIFFICULT AIRWAY MANAGEMENT
6. INDUCTION
7. VENTILATION STRATEGIES
8. MAINTAINENCE
9. EXTUBATION

3.  PEDIATRIC AGE GROUP:
1. NEONATES (preterm / term): birth to 27d
2. INFANTS: 28d to 12month
3. TODDLER: 13m to 2yr
4. CHILDREN: 2yr to 11yr

4. HEAD SIZE
Relatively large head
Anterior flexion causes airway obstruction

5. OBLIGATE NASAL BREATHER

7. THERE IS MARKED DESCENT OF LARYNX BETWEEN BIRTH AND
3YR, REACHING ADULT LEVEL OF C5 – C6 FOLLOWING
PUBERTY

8.  Infant’s vocal cords have
more angled attachment
to trachea, adult’s VC are
more perpendicular
 Difficulty in nasal
intiubation where blindly
placed ETT may easily
lodge in anterior
commissure rather than in
trachea

9. ANTERIOR VIEW POSTERIOR
VIEW

10. TRACHEA

11. ANATOMY OF PEDIATRIC AIRWAY
 SUPRAGLOTTIC FEATURES: PAEDIATRIC
ADULT

12.  SUBGLOTTIC FEATURES: PAEDIATRIC
ADULT

13. Alveoli
 Small and Limited number ( decrease compliance)
 ↑ Closing Capacity & ↑ air trapping
Pulmonary Vessels
 ↑ Pulmonary vascular resistance (PVR)
 Very sensitive to constriction by hypoxia, acidosis and
hypercarbia
Chest Wall
 Horizontal ribs
 ↑ A-P diameter
 ↑ compliance due to cartilagenous rib
 Breathing is all diaphragmatic, easily fatigue due to fewer type
1 muscle cells
 FRC determined solely by elastic recoil of lungs
 Chest wall collapses with negative pressures

14.  Lung compliance is less while chest wall compliance is more
than those in adults - Reduced FRC and Atelectasis
 Prone to Bradycardia - Laryngeal stimulation and hypoxia
 High metabolic rate (5-8 ml/kg/min)
 Oxygen consumption of infant (6 ml/kg/min) is twice that of an
adult (3 ml/kg/min) [Less Oxygen Reserve]
 Tidal volume is relatively fixed (6-7 ml/kg/min)
 Minute Alveolar Ventilation is more dependent on increased
Respiratory Rate than on Tidal Volume
 Ratio of Alveolar Minute Ventilation to FRC is doubled under
circumstances of hypoxia, apnea or anesthesia

15. EFFECT OF EDEMA
Poiseuille’s law: R = 8nl/ πr4

16. SUMMARY

17. Preoperative considerations
History :
● Comorbid illness
● Recent URI
● Obesity
● Anesthesia problems

18.  Best to 1st look from far
1. Any facial anomaly?
2. Is the chest moving? Respiratory rate?
3. Are there any abnormal airway sounds (e.g.. Stridor,
snoring)?
4. Is there increased respiratory effort with retractions or
respiratory effort with no airway or breath sounds?
5. Facial expression
6. Nasal flaring
7. Mouth breathing
8. Color of mucous membranes

19. 9. Voice change
10. Mouth opening
11. Size of mouth
12. Loose or missing teeth.
13. Size and configuration of palate.
14. Size and configuration of mandible (side view).
15. Mallampati score

20.  URI - coughing, laryngospasm, bronchospasm, desaturation
during anesthesia
 Symptoms new or chronic?– Infectious vs allergic
● Viral infection within 2 - 4 weeks of GA with intubation
increases perioperative risk:
Wheezing risk increased 10x
Laryngospasm risk increased 5x
Hypoxemia, atelectesis, recovery room stay, ICU admissions all
increase
Prophylactic bronchodilator treatment should be considered
before induction
Asthamatic pt. may require steroid coverage

21. Congenital heart disease
 CHD associated with high risk of SBE:
1. Unrepaired cyanotic lesions
2. Repaired CHD with prosthetic material with 6m of
procedure
3. Repaired chd with residual defects at / adjacent to site of
prosthetic patch
Prophylaxis only recommended for dental procedure and
invasive procedure of resp. tract
Amoxicillin PO/ ampicillin IV 50mg/kg (max. 2g) /clindamycin/
azithromycin 30 to 60 min before procedure

22. Labs:
Laboratory and radiographic evaluation extremely helpful with
pathologic airway -AP and lateral films and fluoroscopy may
show site and cause of upper airway obstruction
MRI/CT more reliable for evaluating neck masses, congenital
anomalies of the lower airway and vascular system
Radiograph exam done only when there is no immediate threat
to the child’s safety and in presence of skilled personnel with
appropriate equipment to manage the airway
Intubation must not be postponed to obtain radiographic
diagnosis when the patient is severely compromised.
Blood gases are helpful in assessing the degree of physiologic
compromise; however, performing an arterial puncture on a
stressed child may aggravate the underlying airway
obstruction

23. PRE - ANESTHETIC
PREPARATION
 Separation anxiety
● Anxiolysis
● Premedication: Midazolam
0.5mg/kg po/ nasal
(0.2mg/kg), rectal (0.5-1
mg/kg). Dexmed intranasal
(1mcg/kg). Ketamine im (2-
3mg/kg). Opioids – oral
transmucosal fentanyl/
intranasal
● Parental presence during
induction of anesthesia (PPIA)

24. BAG AND MASK VENTILATION

25. OROPHARYNGEAL AIRWAY

26. NASOPHARNYGEAL AIRWAY

27. MASK AND LMA

28. LARYNGOACOPY BLADES

29. ENDOTRACHEAL TUBE
Uncuffed: <3m- 3mm ID
3-9m- 3.5mm ID
>9m- (age in yrs+ 16)/4
TREACHEOSTOMY
TUBE
Age based formula: ID=
age(yrs)/4 +4 mm
Weight based formula: ID=
Wt(kg)/10 +3.5 mm

30. DIFFICULT AIRWAY PREPARATION
anesthesia masks
airway adjuncts (including nasal airways, oral airways, stylets,
intubating guides, tube exchangers, and gum elastic bougies)
ETTs (conventional uncuffed, cuffed, microlaryngoscopy, and
armored), laryngoscope blades (curved, straight, and hybrid),
laryngoscope handles (regular and short)
SGAs (LMAs, classic LMAs as well as intubating and other
LMA hybrids)
indirect video laryngoscopes
different sizes of FOBs
lung isolation devices (bronchial blockers and double lumen
ETTs)
surgical airway access kits
accessory equipment ([ETCO 2 ] detector, (AMBU), and self-

31. SPECIAL CASES REQUIRING DIFFICULT AIRWAY
PREPARATION
 Congenital disorders-
1. Hypoplastic Mandible(micrognathia): Pierre Robin
Sequence, Treacher-Collins , Hemifacial Microsomia (
Goldenhar syndrome)
2. Midface hypoplasia: Apert syndrome, Crouzon syndrome
3. Macroglossia: Hurler’s/ Hunter’s syndrome, Beckwith –
wiedemann syndrome, Down’s syndrome
 Inability to flex/extend the neck
 TM joint dysfunction
 Laryngeal/glottic anomalies( Laryngeal Web )
 Cleft Lip & Palate Cleft Lip
 Traumatic airway

32. AIRWAY
MANAGEMENT
 Positioning:- to align oral,
pharyngeal and tracheal axis
 Suctioning,supplemental
oxygen
 Nebulization with adrenaline
(1:3) or bronchodilators.
Humidification/ steroid
 bag and mask ventilation-
Head tilt, chin lift/ jaw thrust
position
 Oropharyngeal/
nasopharyngeal airway

36. Monitoring during induction
● Age & size appropriate standard monitors
● Preductal pulse oximetry in neonates– Right extremity or
earlobe
● EtCO2 monitor– Main-stream less accurate in < 10 kg; Side-
stream may falsely elevate iCO2 and falsely lower EtCO2
● ECG Leads
● Temperature
● BP cuff
Invasive monitoring
● Require expertise and caution● CVL most often IJV or
femoral Vein
● A-line most often right radial artery– Preductal; for beat to
beat monitoring of BP. ● Bispectral index

37. METHODS OF ANESTHESIA INDUCTION
 INHALATION INDUCTION:
Inhalation of sevoflurane (BG Partition coefficient of 0.68- rapid
onset)
with or without N2O(BG partition coefficient of 0.47-rapid uptake
and distribution) through a mask – M/C used
It is easily reversed when discontinued.
Preffered in patients with known difficult peripheral venous access,
and difficult airways in order to maintain spontaneous ventilation.
LMA inserted untill IV access secured (20- 22G for children, 22-
24G for infants)
Absolute contraindications including malignant hyperthermia,

38. INTRAVENOUS
INDUCTION:
 Advantage – speed of induction; avoids unpleasant odors
and sensations of inhalation
 Disadvantage - difficulty and fear associated with
venipuncture in young children.
 Topical anesthesia, EMLA/ LMX 4 use in Children >6 yrs
Children have larger central compartment and higher
clearance resulting in higher dosing requirements

39. PROPOFOL:
Induction dose of propofol is 2.5 to 3.0 mg/kg in children 3 -12
years
Children <2 years of age require larger dose (2.6 to 3.4 mg/kg),
whereas older children required less.
Induction with propofol in children can cause significant
decreases in blood pressure and inotropy
Advantage - antiemetic properties
Drawback -pain on injection; can be reduced by lidocaine (0.5
mg/kg) IV 30 to 120 seconds before propofol injection or
mixing propofol and lidocaine immediately prior to injection

40. THIOPENTAL
Induction dose in healthy children 5 to 6 mg/kg ; For Infants <2
week- 3.4 mg/kg
Cardiac depressant and vasodilator- should be used with care
in patients suspected of having hypovolemia or decreased
cardiac function.
ETOMIDATE
For patients who have limited hemodynamic reserve
Causes no significant changes in right atrial, aortic, or PAP or
SVR/ PVR after bolus dosing
Induction dose 0.3 mg/kg
Sepsis is relative adrenally insufficient state; not appropriate in
patients with septic shock d/t adrenal suppression
S/E- pain on injection, myoclonic movements

41. KETAMINE
Induction dose of 2 mg/kg IV
Stimulate- release of endogenous catecholamines, elevate
heart rate and blood pressure; used in hemodynamically
fragile patients.
Bronchodilating properties- useful in reactive airway disease
Increases oral and airway secretions; a/w psychological,
behavioral sequelae in children.
Added with antisialogogues (glycopyrrolate 0.1 mg/kg) and
benzodiazepines (midazolam 0.5 mg/kg)

42. RAPID SEQUENCE INDUCTION
 Classic rapid sequence induction involves thorough
preoxygenation, application of cricoid pressure, f/b
hypnotic agent -rapid-acting muscle relaxant -intubation
without mask ventilation.
 Infants and small children have reduced apnea tolerance
d/t increased oxygen demand and poor adherence with
preoxygenation, making them high risk for hypoxemia
during even brief periods of apnea.
 A modified or controlled rapid sequence induction
avoiding cricoid pressure and utilizing gentle mask
ventilation (insufflating pressures <10–12 cm H2O) until
adequate muscle paralysis for intubation performed to
reduce the risk of hypoxemia without increasing the risk of

43. INTUBATION
Technique:
 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
Confirmation :Visualize tube passing through cords ;Breath
sounds and epigastric sounds; End Tidal CO2 (EtCO2)

44. MAINTANANCE OF ANESTHESIA
During maintainance phase, anesthesiologist have to provide
analgesia, amnesia,immobility ensuring hemodynamic
stability
INHALED AGENTS :
1. Nitrous oxide-
 Odorless with very low solubility (blood-gas partition
coefficient of 0.47) that results in rapid uptake and
distribution
 Anesthesia - inhibition of NMDA glutamate receptors in CNS.
 Analgesia- release of endogenous opioids that then
stimulate opioid receptors and spinal level GABA receptors.
 Anxiolysis - activation of GABA
 Accumulates in closed, gas-containing spaces -avoided in
obstructed loops of bowel, pneumothorax, pneumocephalus,
middle ear surgery.

45. SEVOFLURANE
 BG Partition coefficient of 0.68- rapid onset
 Non-pungent odor and minimal airway irritation- up to 8%
sevoflurane can be delivered without breath-holding,
coughing, and laryngospasm.
 MAC - 3.3% in neonates / <6 months old- 2.5% / 6 m- 5
years- 2.0%
 No affect on heart rate, cardiac index, myocardial contractility/
MAP- arrhythmias are uncommon; but prolongs the QTc
interval,when combined with ondansetron.
 Effective bronchodilator; In child >6m- maintains CBF through
autoregulation( until MAP <40% from baseline)

46. DESFLURANE
 BG solubilty coefficient of 0.42, allows for rapid emergence
and recovery.
 MAC :newborns is 9.2% / infants is 8% - 9.9%, /older
children and adults it is 6%
 Highly irritating to upper airway, increase airway resistance,
airway narrowing - coughing,breath-holding, laryngospasm-
not used for induction of anesthesia.
 Provide cardiovascular stability; decrease in SVR and BP, as
well as increases in heart rate, without changes in cardiac
output; Arrhythmias are uncommon.

47. Isoflurane
 BG partition coefficientof 1.4
 MAC –agedependent-1.3% preterm infants/ 1.7% 6m-12
m/1.6% 1 to 5yrs/ 1.2% in adults
 Pungent odor -coughing and laryngospasm- not used for
induction
 Bronchodilator at higher concentration.
 Decrease SVR – decrease systemic arterial pressure and
increase in heart rate but maintaining cardiac output.

48. INTRAVENOUS AGENTS:
 TIVA- for rapid recovery and provide both unconsciousness
and analgesia.
 Newborns /young infants -immature hepatic enzyme systems
and renal clearance -can have accumulation of certain
drugs, so TIVA avoided

49. PROPOFOL:
 short-acting- fast onset, smooth maintenance, no
emergence delirium and decreased incidence of nausea
and vomiting
 highly lipid-soluble, rapidly cleared and redistributed into the
peripheral tissues, with a short context sensitive half-time.
 DOSE: 0.125- 0.3 mg/kg/min
 Prolonged administration or very high dosing over shorter
periods- propofol-related infusion syndrome (PRIS)
characterized by a lactic acidosis and significant
cardiovascular dysfunction

50. DEXMEDETOMIDINE
 Highly selective alpha-2 adrenoreceptor agonist with both
sedative and analgesic properties.
 Elimination half-life-2 hours, with a rapid distribution half-life
of only 6 minutes
 Context-sensitive half-life- 4 minutes for10-minute infusion
but over 250 minutes for 8-hour infusion
 Increase MAP and decrease HR from baseline values after
10-minute loading dose -1 mcg/kg; effects discontinues with
infusion of 0.7 mcg/kg/hr
 SA node function is depressed and AV node properties are
prolonged- used to treat junctional and atrial ectopic
tachycardias as well as SVT

51. VENTILATION STRATEGIES
 For controlled ventilation in healthy infants and children,
appropriate initial ventilator settings should aim tidal volume-
8-10mL/kg.
 Maintenance of PEEP of at least 3-5 cm H2O
 End-tidal CO2 between 35 and 40 mm Hg is the goal, I:E
ratio- 1:2/1:3
 Inverse ratio ventilation needed mostly in ARDS / ALI patient
to improve oxygenation

52.  Initial ventilator settings are as follows:
Ventilator
settings
Premature
neonate
neonate Infant/chil
d
adolescen
t
mode PC PC VC with
pressure
support
VC
Rate 40-50 30-40 20-30 12-15
PEEP 3-5 3-5 3-5 3-5
Inspiratory
time
0.3-0.4 0.3-0.4 0.5-0.6 0.7-0.9
PIP 18-22(if HMD) 18-20 16-18( in
raised ICP);
18-25 (low
compliance)
18-25; 35 (in
severe ARDS)
Fine tuning after initiation is based on blood gases and
oxygen saturation

53.  Targeting oxygen saturation of 90% to 95% in preterm/ 94%
to 98% in term infants and older patients
 For ventilation: RR, Tidal volume( in volume limited), and PIP
(in pressure limited)
 PEEP – to prevent alveolar collapse at end of inspiration, to
recruit collapsed lung spaced or to stent open floppy airways
 In case of hypoxia:
1. Check for circuit connections, oxygen supply, any leak
2. Check position of ETT, any kink/ block(suction)
3. Increase FiO2,MAP
4. Increase tidal volume( in VC), PEEP, Inspiratory
time,PEEP( PC)
5. Others- normalize CO (fluids/electrolytes),maintain normal
Hb / hematocrit, normothermia, deepen sedation, consider
neuromuscular block

54.  If Hypercarbia:
1. VC- increase tidal volume/ rate; asthma patient- increase
expiratory time( >1:3)
2. PC- increase RR/PIP, decrease PEEP
3. Decrease deadspace- shorten ETT, increase CO, decrease
PEEP,vaodilator
4. Decrease CO2 production- increase seadation,decrease
carbohydrate load
5. Suction /Change ETT if blocked,check placement/any kink
6. Fix leak in circuit, ETT Cuff

55. ADJUVANT AGENTS
Used during maintenance phase- allows pain control,
smoother emergence, and immediate postoperative
period.
1. OPIOIDS:
Morphine
Hydromorphone
Fentanyl
Sufentanyl
Remifentanyl
Methadone
Meperidine

56. 2. NON STERIODAL ANTIINFLAMMATORY DRUGS-
ketorolac, acetaminophen
3. HYPNOTICS AND SEDATIVES- Benzodiazepines
4. KETAMINE
5. ANTIEMETICS- ondensetron,
metoclopramide,dexamethasone
6. MUSCLE RELAXANTS- succinylcholine, vecuronium,
rocuronium, cisatracurium, pancuronium

57. 7. REGIONAL ANESTHESIA –
 decrease intraop. requirement of inhaled and iv agents and
allow for a more rapid emergence with effective
postoperative analgesia and minimal sedation
 caudal anesthesia remains most popular regional technique
in this population, epidural anesthesia, field blocks,
ultrasound-guided peripheral nerve blocks, and neuroaxial
opioids
Drugs used- Ropivicaine 0.2%- 1 mg/kg (up to 2 mg/kg)–
Bupivicaine 0.25%- 1 mg/kg (up to 2.5 mg/kg)
Opioids● morphine 25-50 mcg/kg● Hydromorphone 5-10
mcg/kg– Clonidine 2 mcg/kg

58. PERIOPERATIVE FLUID REPLACEMENT
Maintenance fluid requirements were based on Holliday and
Segar formula-
Infant needs 100ml of water per 100kcal expenditure
●1st 0-10 kg → 4 ml/kg/hr
●2nd 10-20 kg → 2 ml/kg/hr
● > 20 kg → 1 ml/kg/hr
● Calculate preoperative deficit : maintainance fluid requirement
X no. Of hours of restriction– Replace 50% fluid deficit +
hourly maintenance fliud required in first hour – Replace 25%
fluid deficit + hourly maintenance fliud required in second hour
and third hour
●M/C : NS ,RL used
● Major surgery → up to additional 10 ml/kg/hr
● Urethral catheter done to monitor U.O and state of hydration

59. TEMPERATURE REGULATION
 Core temperature- measured with an esophageal
probe.
 The safe range for a child’s core temperature is
between 35.5° and 37.5° C.
 To prevent complications due to hypothermia, active
warming, increasing roomtemperature, using radiant
warming lamps, wrapping the child’s head and other
exposed areas, and using warmed intravenous fluids

60. BLOOD LOSS AND BLOOD PRODUCT
REPLACEMENT
● Replace initially with 3 x BSS
or 1 x colloid
MABL =EBV × (Starting
hematocrit -Target
hematocrit)/Starting hematocrit
 Once the MABL is exceeded,
transfuse PRBC
 The volume of PRBC needed
to replace calculated as
follows:
PRBC (ml) = [ Blood loss - ABL]
X Desired
hematocrit/Hematocrit of
PRBC

61. EMERGENCE AND EXTUBATION
 Emergence from GA should be smooth, safe, and well timed.
 While Child is still anesthetized: place an oral airway or bite
block, then do gastric suctioning
 Increasing fresh gas flow and rate of controlled or assisted
ventilation- facilitate elimination of anesthetic gases. To avoid
absorption atelectasis, the use of 100% oxygen should be
avoided.
 As the depth of anesthesia lessens,respiratory pattern and
rate noted.
 A paradoxical breathing pattern- indicate incomplete recovery
from GA, residual paralysis, or upper airway obstruction.
 A rapid RR -indicate inadequate analgesia or Stage 2 of
anesthesia

62.  Transition from Stage 2 to Stage 1 of GA in pre- or nonverbal
children assessed by:
1. Grimacing, which includes eyebrows and/or forehead
2. Conjugate gaze
3. Spontaneous eye opening
4. Purposeful movement, such as reaching for the endotracheal
tube
5. Spontaneous tidal volume >5ml/kg
If neuromuscular blockers used, recovery of TOF ratio over 0.90
,needed to ensure adequate neuromuscular function
 Reversal of neuromuscular blockade- iv atropine (0.02 -0.30
mg/kg) or glycopyrrolate (0.01 mg/kg), followed by neostigmine
(0.06 mg/kg).
 Sugammadex, a rapid-acting reversal agent rocuronium and

63. Clinical criteria of neuromuscular recovery in preverbal and
uncooperative children include:
• Nonparadoxic breathing
• Negative inspiratory pressure generation greater than 30 cm
H2O
• Hip flexion, with leg elevation, for 10 seconds
• Head lift for 10 seconds

64. TRACHEAL EXTUBATION
 ET tube extubation performed when child is fully emerged from
GA (awake extubation) or well anesthetized (deep extubation)
 Awake extubation performed after patient has fully emerged
from Stage 2 of GA -for children with difficult airways and
patients with full stomach precautions.
 Deep extubations - performed whose airway well maintained by
mask ventilation during induction of anesthesia and is still in
Stage 3 of GA,done safely using sevoflurane or desflurane to
allow expedient awakening after extubation.
 Depth of anesthesia confirmed by absence of any response to
suctioning of oral,pharynx and deflation of ET tube cuff

68. EMERGENCE DELIRIUM
It is a dissociated state of consciousness
characterized by inconsolability,thrashing
and incoherence.
 Risk factors include age <5 years ,ENT
and ophthalmologic procedures, use of
isoflurane, rapid emergence (Rapid
awakening in strange environment,
variable recovery of CNS
function,withdrawal from GABA receptors,
inadequately treated pain- major
contributor)
 fentanyl 2.5 mcg/kg, clonidine 2 mcg/kg,
ketamine 0.25 mg/kg, nalbuphine 0.1
mg/kg, or propofol 1 mg/kg
 Dexmedetomidine(donot compromise

69. PROBLEMS IN POST ANESTHESIA CARE
UNIT
 Apnea of prematurity
 Airway obstruction
 Obstructive sleep apnea
 Post obstructive pulmonary edema
 Post intubation Croup
 Cardiovascular Instability
 Nausea / Vomiting
 Temperature instability
 Pain measurement/ assessment/ management

70. ON
Apnea Oversedation with
opioid
Hypocarbia(EtCO2 <4
0
Oversedation- by
synergism of multiple
anesthetic
agents(preoperative
benzodiazepine and/or
inhalational agent
No spontaneous
ventilatory effort
Able to mask-
ventilate patients
EtCO2 can be
high/low
Small or pinpoint
pupils
↑ End-tidal
inhalational agent
concentration
•Bag mask
ventilation to
maintain
SpO2 >94%
•Allow PaCO2 to
rise
•Consider
flumazenil or
naloxone in
recalcitrant
situations
Bronchospas
m
Preexisting URI
Asthma
exposure to
secondhand smoke
Persistent coughing
No breath holding
Wheezing
↓ SpO2- late sign
↑ CO2
•Albuterol
•Epinephrine 0.05
mcg/kg IV if
extreme
Coughing/
breath-
holding
Preexisting URI
Premature extubation-
in stage 2
Bronchiole constriction
exposure to
Persistent coughing
Breath holding
typically <10
seconds
↓ SpO2
•↑ FiO2 via mask
•Apply CPAP with
10-20 cm H2O
•Attempt to wait for
resolution

71. Laryngospasm Premature
extubation in
stage 2
Glottic closure
from stimulation
by ETT or
secretions
Lack of
oropharyngeal
tone
Usually preceded by
cough
Rigid abdominal
wall
Unable to mask-
ventilate even with
oral airway and
elevated ventilatory
pressures
Breath holding for
>10 seconds
↓ SpO2
• attempt mask
ventilation or
apply CPAP with
100% FiO2
•Propofol 1 mg/kg
IV (repeat or
escalate dose if
needed)
•Succinylcholine 1
mg/kg IV/ 4 mg/kg
IM if IV is pulled
out
•Reintubate If
required
Upper airway
obstruction
Collapse of base of
tongue, soft palate
onto posterior
pharyngeal wall d/t
Oversedation with
opioid/BDZ
Residual
inhalational
agent;Underlying
Patient appears to
attempt to breathe but
no breath sounds are
present
Sternal notch sinks in
with attempts at
inspiration
↓ SpO2
Loud upper airway
•Jaw thrust
•10-20 cm H2O of
CPAP
•Oral airway
•Lateral position
•Consider
flumazenil or
naloxone
•Bag-mask