Respiratory Distress/Critical Airway

Deb Updegraff, RN, CCRNClinical Nurse SpecialistLPCH Pediatric Intensive Care Unit

Signs of Respiratory DistressSigns of Respiratory Distress

TachypneaTachypnea TachycardiaTachycardia Grunting Grunting StridorStridor Head bobbingHead bobbing FlaringFlaring Inability to lie Inability to lie

downdown AgitationAgitation

Continued- Signs and Symptoms of Respiratory Distress

•RetractionsRetractions• Use of AccessoryUse of Accessorymusclesmuscles•WheezingWheezing•SweatingSweating•Prolonged expirationProlonged expiration•Pulsus paradoxusPulsus paradoxus•ApneaApnea•CyanosisCyanosis

Causes of Resp DistressCauses of Resp Distress

InfectionsInfectionsPneumoniasPneumonias

BronchiolitisBronchiolitis

EmpyemasEmpyemas

Causes Cont.Causes Cont.

Excessive fluid in the lungExcessive fluid in the lungPulmonary edema (CHF)Pulmonary edema (CHF)

Excessive fluid or air in the pleural spaceExcessive fluid or air in the pleural spacePneumothorax, pleural effusionsPneumothorax, pleural effusions

Upper airway obstructionsUpper airway obstructionsswollen airway, large tonsils, malacias, swollen airway, large tonsils, malacias,

Lower airway obstructionsLower airway obstructionsasthmaasthma

InterventionsInterventions

Comfort measuresComfort measures Patient positionPatient position O2O2 DiureticsDiuretics Broncho-dialatorsBroncho-dialators Nasal trumpetNasal trumpet Positive PressurePositive Pressure Chest tubeChest tube IntubationIntubation

The Pediatric AirwayThe Pediatric Airway

IntroductionIntroduction Anatomy / PhysiologyAnatomy / Physiology PositioningPositioning AdjunctsAdjuncts IntubationIntubation

Anatomy : TongueAnatomy : Tongue

• LargeLarge• Loss of tone with sleep, sedation, CNS Loss of tone with sleep, sedation, CNS

dysfunctiondysfunction• Frequent cause of upper airway Frequent cause of upper airway

obstructionobstruction

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

Photos : Calvin Kuan

Anatomy : EpiglottisAnatomy : Epiglottis

Relatively large size in childrenRelatively large size in children

Omega shapedOmega shapedFloppy – not much cartilageFloppy – not much cartilage

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

Photos: Calvin Kuan

Photo: Calvin Kuan

Airway positioning for children Airway positioning for children <2yrs<2yrs

Photo: Calvin Kuan

Photo: Calvin Kuan

Airway adjunctsAirway adjuncts

Nasal airwayNasal airwayOral airwayOral airway

Adjuncts: Oral AirwayAdjuncts: Oral Airway

Correct sizeCorrect sizePhoto: Calvin Kuan

Nasopharyngeal AirwayNasopharyngeal Airway

Contraindications:Contraindications: Basilar skull Basilar skull

fracturefracture CSF leakCSF leak CoagulopathyCoagulopathy

Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus

Photo: Calvin Kuan

Endotracheal tube as nasal Endotracheal tube as nasal airwayairwayEndotracheal tube as nasal Endotracheal tube as nasal airwayairway

A regular A regular ETT can be ETT can be cut and used cut and used as a nasal as a nasal airway airway

Photo: Calvin Kuan

Intubation: IndicationsIntubation: Indications

Failure to oxygenateFailure to oxygenateFailure to remove COFailure to remove CO22

Increased WOBIncreased WOBNeuromuscular weaknessNeuromuscular weaknessCNS failureCNS failureCardiovascular failureCardiovascular failure

Laryngoscope BladesLaryngoscope Blades

Macintosh

MillerPhoto: Calvin Kuan

Intubation TechniqueIntubation Technique

Straight Laryngoscope Blade – used to Straight Laryngoscope Blade – used to pick up the epiglottispick up the epiglottis

Better in Better in younger children younger children with a floppy with a floppy epiglottisepiglottis

Photo: Calvin Kuan

Intubation TechniqueIntubation Technique

Curved Laryngoscope Blade – placed in the Curved Laryngoscope Blade – placed in the valleculavallecula

Better in Better in older children older children who have a who have a stiff epiglottisstiff epiglottis

Slide: Calvin Kuan

Anatomy : LarynxAnatomy : Larynx

Narrowest point = cricoid cartilage in the Narrowest point = cricoid cartilage in the childchild

Photo: Calvin Kuan

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

Slide: Calvin Kuan

Technique: IntubationTechnique: Intubation

How far How far does it go in does it go in ??

Photo: Calvin Kuan

An Airway is designated CRITICAL by any of the following Criteria

•Airway status post reconstruction surgery

•Difficult airway in the OR per anesthesia

•Patients with syndromes recognized with difficult airwaysMicrognathia- Pierre Robin, Treacher Collins

Cervical Spine abnormalitieS•Goldenhars, Klipper-Fiell

•Macroglossia•Beckwith-Wiedemann, Downs, Achondroplasia

•Soft tissue abnormalities•Submandiibular masses, epiglottis, hemangiiomas

Treacher Collins

Before Mandibular Distraction After Mandibular Distraction

Treacher Collins

HemangiomaHemangioma

Pierre Robin

Goldenhar

Subglottic stenosis is a narrowing of subglottic airway housed In the cricoid cartilage. This is the narrowest area in the pediatric airway.

Airway Reconstructive Surgery- Very Common Critical Airway patient in the PICU

Normal view of trachea

4 month old with acquired Grade III Subglottic stenosis from intubation

Same view: Magnified

Following Cricoid Split Surgical Procedure

Preoperative Subglottic View of 2 year old with acquired verticle subglottic stenosis

After anterior and posterior grafting and successful decannulation of tracheostomy

ICU Check list for Critical Airway:

Patient’s name:

Patient’s Weight:

-Room ready with intubation box.-Critical Airway sign posted at HOB.-Continuous infusion meds ordered (i.e. benzodiazepines, Opioids, muscle relaxants, and others).-Antibiotics and anti-reflux meds ordered.Sign-out has occurred and is documented.-ET tube is secured.-Chest x-ray obtained which is used to determine where the ET tube and CVL are located.

Patient to have arm restraints ordered and placed. Code Pack in the room.Code sheet completed in the room.My Doctor sheet completed and at the head of the bed.