Pediatric Airway Management

1
Pediatric Airway Management

• Tintinelli Chapter 15
• Kelly Hurley, DO

2
Childrens airways

• Larger occiput and tongue
• Rotate head to rest on occiput and remove any
  padding under the head
• Larynx is higher in neck (C3 level), funnel with
  narrowest area subglottic
• Vocal cords are slanted anteriorly
• Airway equivalent to adult by age 8

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Congenital airway abnormalities

• Choanal atresia most common (nose)
• Unilateral or bilateral
• Present several months after birth when there is
  a concurrent problem (URI)
• Tx place oral airway, tube feedings, Sx
• Cystic hygroma benign congenital tumor of
  lyphatic origin
• 60 1st year, 80-90 before 2nd year
• Usually neck, tongue also in mediastinum
• May grow to impair airway Tx with Sx
• Trisomy 21 (Down Syndrome)
• Short neck, small mouth, narrow nasopharynx,
  large tongue, 20 dislocate atlas on axis

4
Congenital airway abnormalities

• Tracheoesophageal fistulas
• 5 types
• Esophageal atresia with distal TEF most common
• Isolated esophageal atresia without TEF
• Isolated TEF
• Esophageal atresia with proximal TEF
• Esophageal atresia with proximal and distal TEF
• Cyanotic, coughing after feeding, catheter cant
  be placed in stomach
• Tx ET tube above carina, but below fistula
  intubate R mainstem bronchi, and pull back until
  B/L breath sounds are heard.

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Congenital airway abnormalities
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Acquired airway abnormalities

• Acute
• Foreign-body aspiration
• Infection laryngotracheobronchitis,
  epiglottitis
• Subglottic edema previous intubation or allergy
• Internal or external airway trauma
• Chronic
• Subglottic stenosis(posttraummatic or
  postsurgical)
• Tumor
• Abscess formation

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Evaluation of Pediatric Airway

• History
• Time course, fever, cough, sore throat
• Previous airway problems
• Review antenatal/perinatal periods
  sleeping/feeding difficulties
• Snoring or noisy breathing, recurrent croup or
  URI, cyanosis or coughing during feeding
• Physical
• Tachypnea, cyanosis, drooling, nasal flairing,
  intercostal retractions, tripod position
• Auscultation stridor, wheezing, grunting
• Change in mental status agitation or somnolence
• Small or recessed mandible, prominent tongue,
  prominent upper incisors, impairment of neck
  mobility

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Pediatric airway equipment

• Oropharyngeal airway
• Extend from the corner of the mouth to just
  cephalad to the angle of the mandible
• Unconscious child
• Nasopharyngeal airway
• Estimate length distance from tip of nose to
  tragus of ear
• Complications damage to adenoid tissue,
  epistaxis, laryngospasm
• Require frequent suctioning
• BVM
• Maximum O2 delivery at flow of 15L/min
• LMA

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Pediatric airway equipment

• ET Intubation
• Straight (Miller) blade is superior to curved
  blade in children younger than 2 years
• Miller size Premature0, Neonate-21,
  2-6Wis-Hipple1.5, 6-122, gt122-3
• Mac size 2-62, 6-122 or 3, gt123
• ETT size
• Infant 2.5mmlt1.5kg, 2.0mm1.5-2.5kg,
  3.5mmgt2.4kg
• Children gt1yr 4age/4
• Resuscitation measuring tapes are more accurate
  (diameter of 5th digit is least accurate)
• Insufficiently snug fit difficulty ventilating,
  compromised airway protection, leakage of
  inhalational agents
• Overly tight-fitting ET injury, subglottic
  stenosis (cuffed tubes avoided gt8yrs old)
• Tube placement either 2nd mark beyond vocal
  cords, or do bronchial intubation and pull back
  to even breath sounds

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Rapid Sequence Intubation

• Preparation
• PreO2
• No BVM risk gastric insufflation and
  regurgitation
• 100 O2 for 2 min or 4 vital capacity breaths
• Premed
• Atropine (0.015-0.2 mg/kg IVP) with
  succinylcholine, prevents bradycardia
• Lidocaine (1.5 mg/kg IV 1-5 min prior) in pts.
  with increased ICP, decreased adrenergic response
  to laryngoscopy, sedatives, NM blockers
• Cricoid pressure
• On cricoid cartilage, occludes esophagus
• Begins after drugs, continues until ETT placed

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Rapid Sequence Intubation

• Induction anesthesia
• Avoid opioid agents for induction because they do
  not reliably induce rapid hypnosis
• Critically ill pts. and those who have received
  other agents need the dose adjusted downward
• Sodium thiopental
• Most commonly used, inexpensive, reliable
• Decreased BP, increased HR
• Lowers ICP and intraocular pressure
• S/E histamine releaseflushing, exaggerated
  hypotension, wheezing, twitching, cough, hiccups,
  extensive tissue necrosis if extravasated.

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Rapid Sequence Intubation

• Propofol
• Like thiopental 1 min onset of action, decrease
  in BP and CO. Difference no increased HR.
• Supresses pharyngeal and laryngeal reflexes can
  use to insert LMA without paralysis.
• Lowers ICP and intraocular pressure
• Use lidocaine to reduce pain upon administration
• More expensive, and must be administered or
  discarded within 6 hours of opening
• Ketamine
• Increase HR, BP, CO (use in trauma, hypovolemia)
• Bronchodilator (good for pts. with reactive
  airway dx)
• 4-6mg/kg IV, onset 5 min
• S.E increased secretions, increased cerebral
  blood flow, ICP, intraocular pressure,
  hallucinations (increased w/benzos)

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Rapid Sequence Intubation

• Midazolam
• Rapid onset time, lack of venous irritation
• Larger doses than for sedation
• Slower onset of action
• Reversed with flumazenil risk of seizures
• Stable hemodynamics, although hypotension with
  hypovolemic or critically ill pts
• S/E apnea (w/opioids)
• Etomidate
• Stable hemodynamic profile
• Lowers cerebral blood flow, ICP
• Lacks analgesic properties, may require 2-4ug/kg
  fentanyl
• S/E pain on injection, myoclonic movements on
  induction, nausea/vomitting

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Neuromuscular Blockers

• Injected immediately after induction agent
• Ensures glottic visualization and ensures the
  vocal cord will be open
• Succinylcholine (Depolarizing)
• Associated with hyperkalemic arrest in children
  with undx myopathies
• 45 sec onset to action, lasts 3-5 min
• S/E hyperkalemia, malignant hyperthermia,
  elevations in IC, IO, IG pressure, prolonged
  blockade (no response to train-of-four monitoring
  10 min after drug), fasiculations (in adults
  defasciculating dose of nondepolarizing NMB
  given), bradycardia (premed with atropine in
  children lt5 y/o or with a HRlt120), masseter
  muscle spasm? myoglobinuria? malignant
  hyperthermia

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Neuromuscular Blockers

• Nondepolarizing
• Vercuronium
• 60-90 sec to onset, duration 90-150 min
• 0.3-0.4 mg/kg
• To speed onset and shorten duration to 60-75 min
  priming dose of 0.1 mg/kg 2-3 min before
  intubating dose of 0.15-0.2
• Stored as powder
• Rocuronium
• Less potent, so faster onset and no priming dose
  needed
• 0.9 mg/kg (75 sec to onset, duration like
  vercuronium) or 1.2 mg/kg (55 sec to onset,
  duration longer)
• Refrigeration needed

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Contraindications to RSI

• Known difficult airway
• Use blind techniques, fiberoptic guidence, or LMA
• Too ill to receive anesthetic drugs (coma,
  hypotensive, without circulation)
• Intubate without using drugs, but use cricoid
  pressure

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Invasive Airway Techniques

• Needle Cricothyroidotomy
• Identify cricoid membrane
• 14g IV cath passed into airway at 45 degree angle
• Remove needle, and use an adaptor to connect BVM
• Transtracheal jet ventilation (TTJV)
  ventilation is provided with short, intermittent
  bursts of O2 at high pressure (50psi), 1s O2
  followed by 4s of expiratory phase
• Complications bleeding, infection, esophageal
  perforation, breakage or bending of needle, SQ
  emphysema, pneumothorax, pneumomediastinum,
  pneumopericardium
• Crichothyroidotomy and Tracheostomy not
  recommended for children in the ER

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Special Considerations

• Head Trauma/Intracranial Mass Lesions
• RSI with strict head and neck immobilization
• Lidocaine 1.5 mg/kg given before laryngoscopy
  blocks rise in ICP that accompanies intubation
• Be prepared for invasive airway management
  secondary to intra-oral or intratracheal injuries
• Epiglottitis and Croup
• Airway management in OR, ventilate until airway
  is established
• Emergent orotracheal intubation can be attempted
  if ventilation fails, followed by invasive
  techniques
• Uncommon for airway placement in croup

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Special Considerations

• Airway foreign bodies
• 5 back blows and 5 chest thrusts in a child
  lt1y/o, abdominal thrusts in child gt1y/o
• In ER try to visualize hypopharyngeal and
  laryngeal areas, or send to OR
• If unstable or completely obstructed, attempt
  orotracheal intubation before cricothyroidotomy

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Quiz

• 1.(T/F) Pediatric airways are equivalent to adult
  airways by age 8.
•  
• 2.The most common tracheoesophageal fistula is
• A.Tracheal atresia with proximal TEF
• B.Tracheal atresia alone
• C.Tracheal atresia with distal TEF
• D.TEF alone
• E.Tracheal atresia with proximal and distal TEF
•  
• 3.(T/F) You should always use a macintosh blade
  in a child.
•  
• 4.To determine the ETT size in a child, use the
  rule
• A.Age 6 /2
• B.Age2 /4
• C.Age4 /4
• D.Age/4 4
•  
• 5.Which drug used in rapid sequence intubation
  should be avoided with increased ICP?
• A.Etomidate