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Robin Foster MD FAAP FACEP Division Chief Pediatric Emergency Medicine Children’s Hospital of Richmond at Virginia
Commonwealth University Health
How hard can it be? � 260 Pediatric Emergency Airway Encounters by Air Transport Personnel � Tollefsen et al Dept EM Brigham Harvard PEC Sept 2013
� 4871 intubations in 3 year period 2007-‐2009 � 260 were pediatric intubations
88 (33.8%) medical 172 (66.2%) trauma #1 head trauma n=64 #2 seizures n=26
How hard can it be? � 260 Pediatric Intubations
� Mean age 7 years � 98.8% orotracheal intubations with RSI � 1st attempt 78.6% n=202 � Ultimate rate 95.7% n=246 � </= 2 attempts 95.9% n=236 � Medical and Surgical diagnoses had equal success rates � All age groups had equal success rates
� 0-‐2 years •8-‐14 years � 3-‐7 years
How hard can it be? � 260 Pediatric Intubations
� 11 patients not successfully intubated � 7 LMA placed � 2 Combitube � 2 Rescue Cricothyrotomy
� Needle Cricothyrotomy in a 2 yo � Surgical Cricothyrotomy in a 14 yo
� No mortality because of a failed endotracheal intubation
� 3 patients 1.1% were managed initially and successfully with EGD
Supraglo5c Airways � Any airway device that sits outside the larynx and forms a seal around it
� Original device: esophageal obturator airway (EOA) 1973
� Complications included: � Incorrect Placement � Esophageal injury � No pediatric sizes
Subglo5c Airways � Combitube is an esophageal tracheal double lumen double cuffed airway developed in the early 1980s
� Ventilation is traditionally provided thru the proximal lumen which opens at the larynx while inflating the distal cuff to obstruct the esophagus
� Two sizes: � 37 4-‐5 foot patient � 41 >5 foot patient
� No pediatric sizes
Pediatric Supraglo5c Airways � King Airway System (LTS-‐D LT-‐D LT) is a curved tube with ventilation apertures located between two balloons with one valve to inflate both the esophageal and the oral pharynx balloon. Introduced US 2003
� Pediatric sizes: � 2.0 35-‐45 inches height pt � 2.5 41-‐51 inches height pt � Average 2 yo 35 inches
Pediatric Supraglo5c Airways � King airways are the most common prehospital supraglottic airway in EMS
� Cuff volumes � 2.0 25-‐35 ml � 2.5 35-‐40ml
� Pediatric sizes for King LT-‐D only: no gastric outlet
Pediatric Supraglo5c Airways � The patent for the first laryngeal mask airway (LMA) was issued to a British anesthesiologist Dr Archie Brain in 1982
� Since then the LMA has been used over 300 millions times in anesthesia and emergency airway management
� Comprised of an airway tube and an elliptical mask with an inflatable or self sealing cuff
� Term LMA has been replaced by the term SGA because of number of new devices
Pediatric Supraglo5c Airways � An update on newer pediatric supraglottic airways with recommendations � Jagannatman et al Ped Anesth April 2015
� Old SGAs � LMA classic 1987 and LMA Unique 1997 � LMA Proseal 2000/ pediatric sizes 2004
� New SGAs � Air Q i-‐gel � LMA Supreme Ambu aura-‐i
Pediatric Supraglo5c Airways LMA Classic-‐1st generation LMA Proseal-‐2nd generation
Pediatric Supraglo5c Airways Air-‐Q-‐2nd generation i-‐gel-‐2nd generation
Inser;on of LMA type SGA
Pediatric Supraglo5c Airways Device Cost $ Smallest size Generation
Gastric out Ease 1st attempt
LMA Classic 80-‐200 1.0 <5kg 1.5 5-‐10kg 2.0 10-‐20kg 2.5 20-‐30kg
1st 91%
LMA Unique 7-‐10 1.0 <5kg 1st 89%
LMA Proseal 100-‐250 1.0 <5kg 2nd 94%
Air-‐Q 7-‐10 0.5<4kg 1st (or 2nd) 99%
Ambu-‐aura 5-‐8 1.0 <5kg 1st (or 2nd) 93%
LMA Supreme 10-‐20 1.0 <5kg 2nd 97%
i gel 10-‐20 1.0 <5kg 2nd 91%
Pediatric Supraglo5c Airways Device Leak pressure
Cm H2O Conduit for intubation
Concerns
LMA Classic 15-‐23 Narrow/long Gastric insufflation(GI)
LMA Unique 15-‐18 Narrow/long Low pressure GI
LMA Proseal 22-‐23 Narrow/long Requires exchange for TI
Air Q 19-‐25 Wide/short
Ambu-‐aura 16-‐22 Wide/short 1.0 and 1.5 φ TI cuffed tubes
LMA Supreme 17-‐20 Narrow/long Requires exchange for TI
i gel 20-‐27 Wide/short Dislodges
Applica;ons of SGA data � If a child has received BMV prior to placement of the SGA then gastric decompression is important either prior to placement of SGA or use SGA with a gastric outlet
� If patient requires ongoing positive pressure ventilation or has intrinsic lung disease then gastric outlet and high leak pressures relevant to ensure adequate ventilation/oxygenation
� If patient ultimately requires definitive airway placement then the shorter wider tubes facilitate conduit tracheal intubation without using exchange catheters/guide wires
Intuba;on of the Pediatric Pa;ent � New indirect laryngoscopes that do not rely on the alignment of the oral-‐pharyngeal-‐tracheal axes
� Potential to benefit pediatric patient population greatly because of the relatively small size of the pediatric airway and the difficulty in obtaining direct visualization of the airway past the small oral opening
� Commonly used current products that have pediatric blades within the last ten years include: � Glidescope � CMAC � Truview EVO2 PCD
Glidescopes � AVL reusable
� 4 size blades GVL 2,3,4,5 � Delay in high level disinfection process
� AVL disposable � Two size video batons
� 1-‐2 neonates/small children � 3-‐4 children /adults
� 6 size blades � Immediately available again to be used
Glidescope Video Batons and Blades are weight based Video baton Blade size Weight parameter (kg)
1-‐2 0 <1.5
1 1.5-‐3.8
2 1.8-‐10
2.5 10-‐28
3-‐4 3 10-‐adult
4 40 and up
The Literature on Glidescopes � Kim et al 2008 British Journal Anesth compared the glidescope with direct laryngoscopy in 203 children � >50% of the time the glidescope provided a better glottic view but a longer time to intubation
� 36 seconds with a glidescope � 23.8 seconds with direct laryngoscopy
� Lee et al 2013 found that a Glidescope blade size that was one smaller than the recommended blade based on weight improved the view of the glottis compared to the recommended GL blade or direct laryngoscopy � Neutral position and jaw thrust manuevers instead of traditional cricoid pressure improved view as well
The Literature on Glidescopes � Validation of the Glidescope video laryngoscope in the pediatric patient Redel et al Ped Anesth July 2009 � 60 patients < 10 years old ASA I-‐III airways � Randomized by airway class to glidescope vs Macintosh intubation
� Anesthesiologists performed the intubations � No significant difference in trauma based on bleeding in the airway comparing glidescope to Macintosh
CMAC � One handle size � Reusable Blade sizes
� Miller 0,1 � Mac 2,3,4
� Disposable Blades � Miller sizes not available
The Literature on CMAC � Studies have looked at infants <10kg (Mutlak et al 2014) as well as older children (Singh et al 2015) in terms of success of intubation and time
� Equal success comparing CMAC with Macintosh � Better visualization of the glottis/cords with CMAC � Slightly longer times to intubate using indirect versus direct larnygoscopy 28 sec vs 26 sec
� Intubations performed by anesthesiologists who had experience with equipment
� Theory is that this difference in time to intubation will persist because of the parallax of placing the tube thru the cords based on an indirect image that requires eye hand coordination
TruView EVO2 � Angled blade � Narrow distal portion � Integrated oxygen jet cleaning system 2-‐5l/min to prevent fogging and provide apneic oxygenation
� Infant blade: 1-‐10kg
The Literature on TruView � Infant (Mutlak et al 2014) and children (Singh et al 2015) comparative studies demonstrate the best visualization of the cords with TruView compared to direct or other indirect devices
� Much longer time to intubate 52 sec vs 28 sec with CMAC and 26 sec with direct laryngoscopy
� No difference in oxygenation but presumptively because of the ability to deliver oxygen during the process
� TruView had much lower user satisfaction scores
Cannot intubate Cannot ven;late neonate or infant � Surgical cricothyrotomy is not indicated because of the small dimensions of the cricothyroid membrane
� Cricoid cartilage is an important circumferential supportive structure for the trachea to maintain patency
� Surgical tracheostomy is the ultimate option but difficult procedure
� Needle cricothyrotomy or needle puncture transtracheal is immediate solution
Needle Cricothyrotomy � Effective ventilation is problematic � High pressure gas flow is required to overcome the small diameter resistance
� No data on using transtracheal jet ventilation on infants and small children
� Animal data Wong et al Peds Anesthesia 2014 � Jet ventilator or a commercial oxygen modulator with noncompliant tubing and a luerlock connected to high flow oxygen both achieve improved oxygenation over the same time frame and sustained it for 15 minutes allowing time to set up for surgical trach
Nitric oxide in Pediatric Acute Respiratory Distress Syndrome � Bronicki et al Multicenter Randomized Trial Journal of Peds Feb 2015
� Hypothesis: Inhaled nitric oxide (iNO) would lead to improved oxygenation and decreased duration of mechanical ventilation in pediatric acute RDS
� 55 children in 9 centers randomized to iNO or placebo
� Survival rate between the two groups at 28 days 92% 22/24 in iNO and 72% 21/29 in placebo (p=0.07) � Significant reduced duration of mechanical ventilation � Significant increased rate of ECMO free survival
Pediatric Airway Cases:#1 � 2 yo male who refuses to eat and is febrile to 102
� Pt is anxious and scared appearing
� Mouth open
Epiglo5;s � Etiologic agents:
� Staph aureus � Group A streptococcus � Candidal supraglottitis in HIV
� Pediatric ENT or anesthesia
� Ceftriaxone and clindamycin
Pediatric Airway Cases: #2 � 18 mo old female with runny nose for two days and now with audible stridor and retractions of intercostals with nasal flaring at rest
Croup � Parainfluenza virus type 1 � Xrays rarely needed unless child excessively febrile or toxic appearing
� AP view with steeple or pencil sign
� Lateral view haziness of the subglottic region and distension of hypopharynx more sensitive and specific
Pediatric Airway Cases: #3 � 5 yo male who has fever chills malaise and decreased po
� Exam with left sided cervical adenopathy and poor visualization of the posterior pharynx
Retropharyngeal Abscess � Prevertebral soft tissue swelling > the width of the vertebrae
� Try to take film in retroflexed position instead of straight upright to avoid false positives
� 6mo-‐6years suppurative changes of retropharyngeal nodes or trauma
� Group A beta hemolytic strep, nonhemolytic strep, Staph aureus or bacteriodes
� CT/OR drainage/clindamycin and zosyn or unasyn
Pediatric Airway Cases:#4 � 18 mo old female who presents with cough, high fever and inspiratory stridor
� Case #2 sent home two nights ago with diagnosis of croup after improving s/p decadron and epinephrine
� Inc WOB and sats 90%
Bacterial Trachei;s � Persistent subglottic narrowing
� Post croup presents much like epiglottitis
� Mucosal damage and impairment of local immune mechanisms secondary to viral infection
� Staph, strep pneum or pyogenes, H influenza and Moraxella
Bacterial Trachei;s � Intubation with anesthesia/pediatric ENT if available
� Ceftriaxone and Clindamycin
Pediatric Airway Cases: #5 � 2 yo male who was in high chair and acutely developed respiratory distress with wheezing and marked increased work of breathing and hypoxia sats 70s
� Pt has a history of asthma but no response to bronchodilators
Aspira;on of beef macaroni and cheese � Expiratory film shows hyperinflation of left chest because of left main stem obstruction
� Intubate right main stem if traditional tube placement fails and oxygenate and ventilate judiciously secondary to risk of ptx
� IV steroids � Rigid bronchoscopy