Pediatric Airway Management

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Pediatric AirwayManagement

• SNOHOMISH COUNTY EMS

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OBJECTIVES

• Anatomy
• Physiology
• Equipment
• Establish respiratory distress present
• Technique
• Post intubation management
• Pitfalls and Pearls
• Difficult airway

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ANATOMY

• Unique lt2 years old
• Approaches normal adult airway by 8 years old
• Glottic opening high and anterior
• C1, transitions to C3/4, then C5/6 by adulthood
• More soft tissue, less tone

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Consider copying fig 20-2 p 270 here
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ANATOMY

• Large tongue in relation to oral cavity
• Large tonsils and adenoids that can bleed (no
  blind nasotracheal intubations)
• Angle of epiglottis to laryngeal opening more
  acute

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ANATOMY

• Large occiput/cranium flexes the neck
• Avoid further neck flexion
• Use sniffing position
• Neck flexed, head extended

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ANATOMY

• Small cricothyroid membrane
• lt3-4 years old almost nonexistant
• gt8 similar to adults
• No surgical cricothyroidotomy lt8
• Cricoid ring most narrow part of airway (below
  vocal cords)

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PHYSIOLOGY

• Smaller floppy upper airway more likely to
  obstruct and more susceptible to swelling
• Resistance is inversely proportional to radius
• R ? 1/r4th power
• Small decrease in airway sizelarge increase in
  airway resistance

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PHYSIOLOGY

• Crying increases the work of breathing 32 times
• Basal O2 requirement 2x that of adults
• FRC (functional residual capacity) 40 of adults
• Only half the alveoli of adults
• Overall, less reserve and faster desaturations

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EQUIPMENT

• Length based systems
• Decrease errors
• Eliminate remembering and completing mathematical
  equations
• Organize equipment

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BROSELOW SYSTEM
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EQUIPMENT

• Self inflating bags smallest 450ml
• Pop off valves that may have to be closed
• Newborn equipment different than peds (0 blades,
  lt50mm oral airways, 250ml BVM, 3-0 tubes)

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RESPIRATORY DISTRESS

• Rapid 30 second assessment
• T one
• I nteractive
• C onsolablity
• L ook/track
• S peech/cry

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RESPIRATORY DISTRESS

• Altered mental status
• Nasal flaring
• Head bobbing
• Accessory muscle use
• Grunting

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RESPIRATORY DISTRESS

• You must undress the patient
• Retractions
• Substernal
• Intercostal
• Supraclavicular
• Suprasternal

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RESPIRATORY DISTRESS

• Infants are nose breathers
• Secretions can impeded air flow
• Bulb syringe nasal suction may alleviate this

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RESPIRATORY FAILURE

• Impending respiratory arrest
• All of the above signs diminish
• Respiratory rate diminishes
• Mental status diminishes
• Child becomes quiet
• Mottling may develop

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TECHNIQUEMEDICATIONS

• Succinylcholine
• Dose higher at 1.5mg/kg
• Etomidate
• 0.3mg/kg
• Fentanyl
• 1-3mcg/kg consider for age gt10 and head injury

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TECHNIQUEMEDICATIONS

• Vecuronium
• 0.1mg/kg
• Rocuronium
• 1mg/kg

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TECHNIQUE MEDICATIONS

• Atropine
• Routine use not recommended
• Should be available and prepared in case it is
  needed (more common in children lt1)
• 0.02mg/kg

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TECHNIQUE HEAD POSITION

• Sniffing position
• Slight anterior displacement of neck (pulling
  chin up)
• Small infants may require elevation of shoulders
  with a towel to counteract a large occiput
  flexing head
• Older children may require a towel under the head
• Goal is to align ear canal anterior to shoulders
• Head tilt chin lift or Jaw thrust (trauma
  patients)

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Picture Fig 21-1 page 284
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TECHNIQUE OXYGEN SUPPLEMTATION

• Oxygen may be delivered by
• Blow by
• Nasal cannula
• Face mask
• Forcing the child to struggle with nasal cannula
  oxygen increase oxygen demand
• Blow by may suffice

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TECHNIQUE BVM

• BVM alone may suffice for short transports
• Pediatric airway obstruction usually amenable to
  BVM
• The extra thoracic trachea is collapsible in
  children, so with increased negative pressure
  from inspiration during obstruction, obstruction
  may become worse and BVM may help

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TECHNIQUE BVM

• Dont compress submental tissue
• Hold angle of mandible
• Use C-Clamp technique (solo)
• Use 2 providers when possible
• Dont put pressure on eyes (causes vagal
  response)

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TECHNIQUE BVM

• Normal tidal volume 8-10ml/kg
• Watch for adequate chest rise
• Squeeze-Release-Release to allow for exhalation
• Only use enough force to see chest rise
• 8-10 BPM code, 12-20 alive (monitor end tidal CO2)

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TECHNIQUE BVM

• Avoid gastric insufflation
• Avoid excessive peak inspiratory pressure
• Ventilate slowly and watch for chest rise
• Slight cricoid pressure (excessive will compress
  trachea in peds)

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TECHNIQUE BLADES

• Follow Broselow guide
• Miller straight blade better until about age 5
• Lifts disproportionately large epiglottis out of
  way

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TECHNIQUE CRICOID PRESSURE

• Insufficient evidence to routinely recommend
  cricoid pressure during intubation (as opposed to
  BVM)

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TECHNIQUE LAYNGEAL MANIPULATION

• Use as needed
• Frequently
• B ackward
• U pward
• R ightward
• P ressure

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TECHNIQUE TUBES

• Use Broselow guide
• Be prepared with tubes 0.5mm larger and smaller
• Narrowest part of airway is below cords
• If tight, use smaller tube
• If large air leak, use larger tube or same size
  tube with cuff
• Small air leak, no worries if adequate chest
  rise, O2 sat, end tidal CO2

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TECHNIQUE TUBES

• Cuffed tubes
• Are OK
• Cuff pressure needs to be monitored (20-25cm
  water)
• Dont have to be inflated
• In general, go a size smaller if using cuffed
  tube for size lt6.0
• Too large a tube/too high cuff pressure)laryngeal
  tracheal stenosis which can develop rapidly

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TECHNIQUE TUBES

• Tube insertion depth
• Follow Broselow
• 3x size of tube (4.0 ETT12cm insertion length at
  teeth)
• Secure tube, immobilize neck, as short trachea
  predisposes to moving tube too far in with neck
  flexion, and out with neck extension

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TECHNIQUE CONFIRM PLACEMENT

• Tube fogging
• B/L breath sounds
• Silent epigastrum
• End Tidal CO2
• Pulse ox

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TECHNIQUE END TIDAL CO2

• Peds detectors up to 15kg (adult detectors have
  too much dead space in circuit)
• Adult detectors over 15kg (peds detectors will
  cause too much resistance

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TECHNIQUE END TIDAL CO2

• In cardiac arrest
• If lt10-15mmHg, focus on improving CPR and avoid
  over ventilation
• An abrupt and sustained increase may signal
  return of spontaneous circulation
• In non arrest
• Titrate to clinical condition (35-45 unless head
  injury/impending herniation 25-30)

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POST INTUBATION MANAGEMENT

• Adequate sedation
• Benzodiazepines
• Diazepam 0.2mg/kg (max 10mg/dose)
• Lorazepam 0.05mg/kg (max 2mg/dose)
• Midazolam 0.1mg/kg (max 2mg/dose)
• Opiates
• Fentanyl 1-3mcg/kg (max 50mcg/dose)
• Morphine 0.05-0.2mg/kg (max 5mg/dose)
• Paralytics as needed
• Rocuronium 1mg/kg
• Vecuronium 0.1mg/kg

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POST INTUBATION MANAGEMENT

• Problems
• D isplacement of tube (confirm placement)
• O obstruction of tube (pass suction catheter)
• P neumothorax
• E quipment failure (unhook from vent, check O2)

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PITFALLS AND PEARLS

• Performance anxiety
• Equipment stocking and testing
• Troubleshooting
• Periodic training and practice

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DIFFICULT AIRWAY

• Infectious disease causes
• Noninfectious causes including trauma
• Congenital abnormalities

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DIFFICULT AIRWAY INFECTIOUS DISEASE

• Epiglottitis
• Croup
• Retropharyngeal abscess
• Bacterial Tracheitis
• Ludwigs angina

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DIFFICULT AIRWAY INFECTIOUS DISEASE

• Small changes in airway diameter have a large
  impact on airway resistance
• Crying increases work of breathing 32 times
• Dont over treat

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EPIGLOTTITIS

• If stable, leave patient with parent in position
  of comfort
• 2 person bag valve mask ventilation can be
  sufficient
• If needed, intubation can be attempted with a
  smaller than predicted tube
• Push on chest to try to see bubbles coming from
  airway if visualization obstructed
• One of the few indications for needle
  cricothyrotomy if all else fails

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CROUP

• Subglottic narrowing
• Tube may fit through cords, but then get snug
• Use smaller than expected tube
• BVM can work, but requires 2 people and possible
  high pressure

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DIFFICULT AIRWAY NONINFECTIOUS DISEASE

• Foreign body
• Burns
• Anaphylaxis
• Caustic ingestion
• Trauma

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FOREIGN BODY

• Conscious
• Consider doing nothing if patient stable
• Back blows less than age 1 year
• Heimlich (age greater than 1)
• Unconscious
• BVM may work
• Direct laryngoscopy
• Removal of object
• Push it down and move the tube back to normal
  position
• Needle cricothyrotomy will only work if
  obstruction is above the cricothyrotomy level
  (you should see it but cant remove it)

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BURNS, ANAPHYLAXIS, CAUSTIC INGESTIONS, TRAUMA

• If condition is decompensating and/or not
  responding to treatment, consider early
  intervention
• Should consider medications first in anaphylaxis

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CONGENITAL ABNORMALITITES

• Dont try unless you have to
• May be more reasonable to support until
  respiratory failure/arrest has occurred
• Treat for causes of respiratory distress

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CONGENITAL ABNORMALITITES MICROGNATHIA

• Small mandible reduces the space to which the
  tongue and soft tissue can be displaced out of
  your way

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DIFFICULT AIRWAY ADJUNCTS

• LMA
• Needle cricothyrotomy
• Combitube/King LT

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DIFFICULT AIRWAY LMA

• Can be used in all ages
• In small infants more complications
• Causes obstruction with relatively large
  epiglottis
• Easy to lose adequate seal with movement
• Air leaks
• Recommend inserting upside down and rotating it
  as advanced back
• Not for foreign bodies, caustics, burns

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NEEDLE CRICOTHYROTOMY

• For use when you cant intubate or ventilate
• For use in children lt8-10 years old
• Not helpful for croup or distal foreign bodies

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NEEDLE CRICOTHYROTOMY

• Extend head, towel under shoulders
• Identify landmarks
• Insert catheter (14g) over the needle at a 30
  degree angle directed toward feet
• Aspirate air
• Slide catheter off needle and remove needle
• Attach 3mm ETT adapter and begin BV

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NEEDLE CRICOTHYROTOMY

• Will require excessive force due to small
  catheter diameter
• Pop off valve should be disabled
• Does not protect airway
• Does not allow for adequate ventilation, only
  oxygenation

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NEEDLE CRICOTHYROTOMY

• Complications
• Inappropriate needle placement
• Inadequate ventilation (hypercarbia and acidosis)
• Obstruction of small catheter
• Subcutaneous emphysema

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NEEDLE CRICOTHYROTOMY

• TTV
• For use gt5 years
• Supraglottic patency required to allow for
  exhalation (air stacking)
• Barotrauma
• Start with 20 PSI and adjust to chest rise
• Requires no more than of 1 second inspiration,
  then 3 seconds to exhale
• Nasal/oral airway should be placed as well

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COMBITUBE/KING LT

• Double/single lumen tube designed to be place in
  esophagus
• Must be 4ft tall for small Combitube
• May not protect against aspiration
• Not for caustic ingestion or significant
  esophageal pathology

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