Pediatric Pearls I

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Pediatric Pearls I

• Delon F.P. Brennen MD,MPH
• Pediatrics / Pediatric Emergency Medicine
• Morehouse School of Medicine

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Objectives

• Pediatric Airway and Airway Management
• Discuss Airway/Respiratory Emergencies

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The Pediatric Airway

• Anatomy / Physiology
• Positioning
• Adjuncts
• Intubation

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Introduction

• Almost all pediatric codes are of respiratory
  origin

Internal Data. B.C. Childrens Hospital,
Vancouver. 1989.
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Pediatric Cardiopulmonary Arrests
10
10
80
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Anatomy
Children are very different than adults !!!
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Pediatric Airway

• Anatomy Issues
• Large head that tends to flex the short neck and
  obstruct the airway
• Disproportionately large tongue
• Larynx is more cephalad and anterior
• Cricoid cartilage is the narrowest point of the
  airway until about age 8
• Shorter trachea leaves less margin for error in
  placement of the endotracheal tube

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Anatomy

• Nose
• Responsible for 50 of total airway resistance at
  all ages
• Infants are obligate nasal breathers blockage of
  nose respiratory distress

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Anatomy

• Tongue
• Large
• Loss of tone with sleep, sedation, CNS
  dysfunction
• Frequent cause of upper airway obstruction

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Anatomy

• Larynx
• High position / Cephalad
• Infant C1
• 6 months C3
• Adult C5-C6
• Anterior position

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Children are different
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Anatomy Larynx

• Narrowest point cricoid cartilage in the child

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Anatomy

• Epiglottis
• Relatively large size in children
• Floppy not much cartilage
• Omega (W) -shaped

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Physiology Effect of Edema
Poiseuilles law
8 n l
R
? r4
If radius is halved, resistance increases 16-fold
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Airway positioning for children lt2yrs
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Airway Positioning
Sniffing Position In the child older than 2
years
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Airway adjuncts

• Nasal airway
• Oral airway

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Nasopharyngeal Airway
Length Nostril to Tragus

• Indications
• Conscious Patient
• Upper Airway obstruction prolapse of tongue
  and mandibular block of tissue into the posterior
  pharynx

Contraindications Basilar skull fracture CSF
leak Coagulopathy
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Endotracheal tube as nasal airway
A regular ETT can be cut and used as a nasal
airway
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Oral Airways
Measure Lips to angle of the mandible
Never in a conscious patient !!!
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Adjuncts Oral Airway
Wrong size Too Long
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Adjuncts Oral Airway
Wrong size Too Short
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Adjuncts Oral Airway
Correct size
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Signs of Respiratory Distress ?

• Tachypnea
• Tachycardia
• Grunting
• Stridor
• Head bobbing
• Flaring
• Inability to lie down
• Agitation

• Retractions
• Access muscles
• Wheezing
• Sweating
• Prolonged expiration
• Pulsus paradoxus
• Apnea
• Cyanosis

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Impending Respiratory Failure

• Reduced air entry
• Severe work
• Central Cyanosis despite O2
• Irregular breathing / apnea
• Grunting
• Altered Consciousness
• Diaphoresis

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Intubation Indications

• Failure to oxygenate
• Failure to remove CO2
• Increased WOB
• Neuromuscular weakness
• CNS failure
• Cardiovascular failure

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Intubation

• Larynx cephalad and anterior in children
• Practitioner may need to be lower than patient
  and look up

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Laryngoscope Blades
Macintosh
Miller
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Intubation Technique
Straight Laryngoscope Blade (Miller) used to
pick up the epiglottis
Better in younger children with a floppy
epiglottis
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Intubation Technique
Curved Laryngoscope Blade (Mac) placed in the
vallecula
Better in older children who have a stiff
epiglottis
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Intubation
Age kg ETT Length
(lip) Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1
yr 10 4.0 11 2 yrs 12 4.5 12
Children gt 2 years ETT size
Age/4 4 ETT depth (lip) Age/2 12
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Technique Intubation
How far does it go in ?
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Deterioration after Intubation

• Displaced tube
• Obstructed tube
• Pneumothorax
• Equipment

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Questions ?

• Oh, it aint over!

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The Test

• 6 week old infant comes to the ED with signs of
  respiratory distress. Which of the following
  would be consistent with impending respiratory
  failure?
• Bilateral basilar rales
• Resp Rate 45bpm
• Audible Grunting
• Wheezing at the axillae
• Acrocyanosis

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Question 2

• 14 month old comes to the ED with cyanosis,
  tachypnea, and altered mental status. Which of
  the following supports the decision to intubate
  the childs trachea immediately?
• ABG with pH 7.25
• Pulse ox of 87 on RA
• PaCO2 of 56mmHg
• PaO2 of 56mmHg
• Clinical assessment of respiratory failure

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Question 3

• Unconscious 15yo brought to the ED because of
  massive facial trauma and bleeding. He was
  punched and kicked by 4 girls and is now in
  respiratory distress. Which is the best method of
  securing his airway?
• Nasopharyngeal airway
• Nasotracheal intubation
• Oropharyngeal airway
• Cricothyroidotomy
• Bag-Valve Ventilation
• Testicular Implant

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Question 4

• 6 week old brought to the ED. Mother is concerned
  that her baby ain ackin right. Which of the
  following vital signs reflect respiratory
  distress, failure, and shock?
• RR 60bpm, HR 160bpm, SBP 75mmHg
• RR 50bpm, HR 150bpm, SBP 75mmHg
• RR 80bpm, HR 180bpm, SBP 60mmHg
• RR 45bpm, HR 130bpm, SBP 80mmHg
• RR 30bpm, HR 100bpm, SBP 70mmHg

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Question 5

• Which of the following physical findings is seen
  only in lower airway disease?
• Audible grunting
• Inspiratory Stridor
• Tachypnea
• Rales
• Cyanosis

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Question 6

• 5 yo with Asthma arrives in AE in acute
  distress. Patient has marked tachypnea, subcostal
  retractions, and diffuse wheezing. Which method
  of O2 delivery will deliver the highest possible
  concentration of oxygen?
• Nasal cannulae
• Face tent
• Nonrebreather mask
• Venturi mask

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Question 7

• You have just intubated the trachea of a 6 month
  old. Which of these best demonstrates the correct
  placement of an endotracheal tube?
• Bilateral breath sounds over the chest abd
• Condensation in the tube
• Slight improvement in the O2 saturation
• Assessment of end-tidal CO2
• Chest wall movement

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Question 8

• 3 hours later while receiving mechanical
  ventilation, the child acutely decompensates.
  Which of the following would be the least helpful
  in the management of this child?
• Suction the ET
• ABG
• CXR
• Auscultate both lung fields
• Evaluate the ventilator

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Question 9

• Infants are more susceptible than adults to
  respiratory emergencies because of which of the
  following?
• Greater resistance in lower airways
• Larger tongue, small mandible, soft epiglottis
• More compliant, less stable chest wall
• Higher metabolic requirements
• All of the above

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Question 10

• 3yo brought to the ED after parents noted
  coughing while playing. Now have dyspnea and
  stridor. Which of the following is indicated at
  this time?
• Four hard back blows
• Finger sweep of childs mouth
• Nasotracheal intubation
• Abdominal thrusts
• Nebulized racemic epinephrine

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Question 11

• Pulse oximetry can be accurately used to monitor
  patients with all of the following except
• Hypoxemia
• Carbon monoxide poisoning
• Sickle cell disease
• Cystic fibrosis
• Cyanotic heart disease

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Question 12

• Which of the following clinical conditions is NOT
  an indication for intubation?
• Hypoventilation
• Loss of protective airway reflexes
• Severe bronchospasm
• Metabolic alkalosis
• Pulmonary toilet

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Question 13

• Is that enough?

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Issues?