pediatric airway management winkler
TRANSCRIPT
Pediatric Airway Pediatric Airway ManagementManagement
Margaret Winkler, MDMargaret Winkler, MD
Pediatric Critical CarePediatric Critical Care
University of Alabama at University of Alabama at BirminghamBirmingham
The Pediatric AirwayThe Pediatric Airway
IntroductionIntroduction Anatomy / PhysiologyAnatomy / Physiology PositioningPositioning AdjunctsAdjuncts IntubationIntubation
IntroductionIntroduction
Almost all pediatric “codes” are of Almost all pediatric “codes” are of respiratory originrespiratory origin
Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.
Pediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary Arrests
1° Respiratory
Shock
1° Cardiac
1° Respiratory
Shock
1° Cardiac
10% 10%
80%80%
Age distribution of arrestsAge distribution of arrests
0
5
10
15
20
25
30
35
40
<7 mos 151413121110987654321
7-12
mos
Age (years)
# A
rres
ts
Schindler M, et al. Outcome of out-of-hospital cardiac or Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479.respiratory arrest in children. N Engl J Med 1996;335:1473-1479.
Arrive in ER in Arrive in ER in cardiac arrestcardiac arrest
(N = 80)(N = 80)
Admit PICUAdmit PICU(N=43) 54 %(N=43) 54 %
Died in ERDied in ER(N=37) 46%(N=37) 46%
Mod DeficitMod Deficit(N=3)(N=3)
PVS at PVS at 12 mos12 mos(N=2)(N=2)
Dead at Dead at 12 mos12 mos(N=1)(N=1)
Died in ICUDied in ICU(N=37) 46%(N=37) 46%
AnatomyAnatomy
Children are very different than adults !!!Children are very different than adults !!!
Anatomy : NoseAnatomy : Nose
• Nose is responsible for 50% of total airway Nose is responsible for 50% of total airway resistance at all agesresistance at all ages
• Infant: blockage of nose = respiratory Infant: blockage of nose = respiratory distressdistress
Anatomy : TongueAnatomy : Tongue
• LargeLarge• Loss of tone with sleep, sedation, CNS Loss of tone with sleep, sedation, CNS
dysfunctiondysfunction• Frequent cause of upper airway obstructionFrequent cause of upper airway obstruction
Anatomy : LarynxAnatomy : Larynx
• High positionHigh position• Infant : C 1Infant : C 1
• 6 months: C 36 months: C 3
• Adult: C 5-6Adult: C 5-6• Anterior positionAnterior position
Children Children areare different different
Anatomy : LarynxAnatomy : Larynx
Narrowest point = cricoid cartilage in the childNarrowest point = cricoid cartilage in the child
Anatomy : EpiglottisAnatomy : Epiglottis
• Relatively large size in childrenRelatively large size in children• Omega shapedOmega shaped• Floppy – not much cartilageFloppy – not much cartilage
Physiology: ResistancePhysiology: Resistance
Peripheral airways contribute to total airways Peripheral airways contribute to total airways resistance:resistance:
AdultAdult 20%20%
ChildChild 50%50%
Physiology: Effect of EdemaPhysiology: Effect of EdemaPoiseuille’s lawPoiseuille’s law
If radius is If radius is halvedhalved, resistance increases , resistance increases 16fold16fold
R =R = 8 n l8 n l rr44
Airway positioning for Airway positioning for children <2yrschildren <2yrs
Airway PositioningAirway Positioning
““Sniffing Position”Sniffing Position”In the child older than 2 yearsIn the child older than 2 years
Towel is placed under the headTowel is placed under the head
Airway adjunctsAirway adjuncts
• Nasal airwayNasal airway• Oral airwayOral airway
Nasopharyngeal AirwayNasopharyngeal Airway
Contraindications:Contraindications: Basilar skull fractureBasilar skull fracture CSF leakCSF leak CoagulopathyCoagulopathy
Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus
Endotracheal tube as nasal airwayEndotracheal tube as nasal airwayEndotracheal tube as nasal airwayEndotracheal tube as nasal airway
A regular ETT A regular ETT can be cut and can be cut and used as a nasal used as a nasal airway airway
Adjuncts: Oral AirwayAdjuncts: Oral Airway
Wrong size: Too LongWrong size: Too Long
Adjuncts: Oral AirwayAdjuncts: Oral Airway
Wrong size: Too ShortWrong size: Too Short
Adjuncts: Oral AirwayAdjuncts: Oral Airway
Correct sizeCorrect size
Oral AirwaysOral Airways
Signs of Respiratory DistressSigns of Respiratory Distress
• TachypneaTachypnea• TachycardiaTachycardia• Grunting Grunting • StridorStridor• Head bobbingHead bobbing• FlaringFlaring• Inability to lie downInability to lie down• AgitationAgitation
• RetractionsRetractions• Access musclesAccess muscles• WheezingWheezing• SweatingSweating• Prolonged expirationProlonged expiration• Pulsus paradoxusPulsus paradoxus• ApneaApnea• CyanosisCyanosis
Impending Respiratory FailureImpending Respiratory Failure
• Reduced air entryReduced air entry• Severe workSevere work
• Cyanosis despite OCyanosis despite O22
• Irregular breathing / apneaIrregular breathing / apnea• Altered ConsciousnessAltered Consciousness• DiaphoresisDiaphoresis
Respiratory FailureRespiratory Failure
• Hypoxic respiratory failureHypoxic respiratory failure• Hypercarbic respiratory failureHypercarbic respiratory failure
HypoxemiaHypoxemia
• Inadequate inspiratory Inadequate inspiratory partial pressure of oxygenpartial pressure of oxygen
• Global alveolar Global alveolar hypoventilationhypoventilation
• Right to left shuntRight to left shunt• V/Q mismatchV/Q mismatch• Incomplete diffusion Incomplete diffusion
equilibriumequilibrium
•Low barometric pressure or Low barometric pressure or FIO2FIO2•High PaCO2High PaCO2
•Little change with extra oxygenLittle change with extra oxygen•Good response to O2Good response to O2•Good response to O2Good response to O2
MechanismMechanism Distinguishing AttributeDistinguishing Attribute
Incomplete diffusion equilibriumIncomplete diffusion equilibrium
• Thickened alveolocapillary membrane (true Thickened alveolocapillary membrane (true diffusion block)diffusion block)
• Abnormally low oxygenation of mixed Abnormally low oxygenation of mixed venous blood venous blood
• Lung damage or destruction, resulting in Lung damage or destruction, resulting in reduced alveolar capillary volumereduced alveolar capillary volume
• Increased CO with reduced alveolar Increased CO with reduced alveolar capillary transit timecapillary transit time
Intubation: IndicationsIntubation: Indications
• Failure to oxygenateFailure to oxygenate• Failure to remove COFailure to remove CO22
• Increased WOBIncreased WOB• Neuromuscular weaknessNeuromuscular weakness• CNS failureCNS failure• Cardiovascular failureCardiovascular failure
IntubationIntubation
• Larynx cephalad and anterior in Larynx cephalad and anterior in childrenchildren
– Practitioner may need to be Practitioner may need to be lowerlower than patient and than patient and look uplook up
Cephalad and anteriorCephalad and anterior
Laryngoscope BladesLaryngoscope Blades
Macintosh
Miller
Intubation TechniqueIntubation Technique
Straight Laryngoscope Blade – used to pick up Straight Laryngoscope Blade – used to pick up the epiglottisthe epiglottis
Better in younger Better in younger children with a children with a floppy epiglottisfloppy epiglottis
Intubation TechniqueIntubation Technique
Curved Laryngoscope Blade – placed in the valleculaCurved Laryngoscope Blade – placed in the vallecula
Better in older Better in older children who children who have a stiff have a stiff epiglottisepiglottis
IntubationIntubation
AgeAge kgkg ETTETT Length (lip) Length (lip)
NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212
Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12
Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12
Technique: IntubationTechnique: Intubation
How far does How far does it go in ?it go in ?
Deterioration after IntubationDeterioration after IntubationDeterioration after IntubationDeterioration after Intubation
• DDisplaced tubeisplaced tube
• OObstructed tubebstructed tube
• PPneumothoraxneumothorax
• EEquipmentquipment
• DDisplaced tubeisplaced tube
• OObstructed tubebstructed tube
• PPneumothoraxneumothorax
• EEquipmentquipment