Paediatric Airway Emergencies

1
Paediatric Airway Emergencies

• DR. D. Mannion.
• Chairman Dept of Anaesthesia Critical Care
• OLCH Crumlin

2
Objectives

• Why are children different?
• Anatomy
• Physiology
• Routine management of paediatric airway
• Common problems
• Management of difficult airway.
• Anticipated
• Unanticipated

3
ANATOMY

• Supra Glottic
• Narrow nares
• Large tongue
• Epiglottis large and floppy
• Larynx more anterior
• Larynx more cephalad C3 C4

• Sub Glottic
• Narrow cricoid ring
• Trachea 2-5 cm short
• Bronchi more horizontal
• Small cricothyroid membrane
• Mobile compliant trachea

4
PHYSIOLOGY

• Lung volume smaller in proportion
• Metabolic rate is twice an adults
• Greater VO2 6ml/kg v 3 ml/kg in adult
• Vent requirement per unit lung is greater
• Airway resistance is greater due to small airways
• High respiratory rates

5
Physiology practical implications

• Great for inhalational inductions
• Great for maintaining inhalational anaesthesia
• BUT
• If airway obstructed they rapidly desaturate.

6
Also

• Neonates obligate nasal breathers until 2-5
  months of age.
• Tonsils and adenoids appear at 2 years and reach
  max size at 4 7 years. Snoring, sleep apnoea
  and upper airway obstruction when unconscious.

7
COMMON DIFICULTIES

• Position
• Neutral position small role under shoulders
• Over extended neck worsens obstruction
• Mask
• Shouldnt occlude nostrils, pressure on eyes
• Chin Lift
• Pressure on submental tissues occludes airway as
  tongue is pushed up into palate.
• Jaw thrust most effective manouvere

8
LARYNGOSCOPY

• Straight blade picks up epiglottis
• Mobile larynx means cricoid pressure can
  considerably improve the view.
• Vocal cords angled anterior commisure may hitch
  tracheal tube rotate it.
• Most ET tubes are marked with black line to
  indicate how far to insert.

9
Microlaryngoscopy

• Inhalational technique
• IV anaesthesia technique

10
Common problems

• Laryngospasm
• UAO
• Laryngeal obstruction
• Epiglottitis/Papillomatosis/Vocal cord palsy
• Foreign body
• Sub glottic oedema/ Tracheomalacia
• Mediastinal mass
• Difficult intubation

11
Upper airway obstruction

• Laryngomalacia commonest congenital stridor

12
Laryngomalacia

• Presents 2 weeks
• Stridor feeding difficulties
• Gone by 18 24 months

13
Laryngospasm

• BCH experience
• 210 cases over 6 years
• Inadequate depth of anaesthesia usual factor
• Commonest lt 6 years and lt 1 yr
• Experience of anaesthetist influenced occurence

14
Laryngospasm - treatment

• CPAP O2 successful in third of cases
• Deepen anaesthesia - Propofol over 70 of
  cases.
• Muscle relaxant

15
Laryngospasm - prevention

• Adequate depth of anaesthesia
• ALWAYS HAVE IV BEFORE LARYNGOSCOPY
• Spray cords with local if working on airway
• Remove LMA early and ET either anaesthetised or
  awake.

16
Laryngeal obstruction

• Epiglottitis
• Papillomatosis
• Haemangioma
• Laryngeal web
• Vocal cord palsy

17
Papillomatosis

• HPV 6 11
• Repeated microdebriement
• Cidofovir ??
• Dont intubate.
• Discard circuit after single use.

18
Haemangiomas

• Laser
• Tracheostomy
• Steroids
• B Blockers
• Propranolol
• Acetbutalol

19
Vocal cord paralysis

• Idiopathic, neurological, iatrogenic, birth
  trauma.
• Stridor, feeding difficulties
• 70 resolve.

20
Foreign Body
21
FB post removal
22
Laryngeal Cleft
23
Laryngeal Cleft Grade 1
24
(No Transcript)
25
(No Transcript)
26
Difficult airway

• Difficult intubation
• 0.08 healthy 0.42 all children
• Anaesthesiology 2007107A1637
• 0.095 lt 16 yrs 0.24 lt 1 yr
• Paediatr Anaesth 2004.
• Cant ventilate
• lt0.02 difficult but never impossible.
  Anaesthesiology 2007107A1637
• Adults 0.15 difficult to ventilate
• Anaesthesiology 2009 110891

27
Diff ventilation

• More common in less experienced hands
• Anatomical
• Functional
• Laryngospasm
• Light anaesthesia
• Inflated stomach
• Bronchospasm.

28
Difficult intubation/ventilation

• Anticipate
• Have a plan A, plan B and C if necessary.
• Maintain oxygenation
• Tracheostomy
• DONT PANIC!!!
• GET HELP

29
ANTICIPATE

• Congenital
• Cranio-facial abn Pierre-Robin etc.
• Laryngotracheal web, stenosis, malacia
• Structural
• foreign body, stenosis, burns, oedema, vascular.
• Inflammatory
• Croup, epiglottitis, papillomatosis, abscess
• Neoplastic
• Cystic hygroma, tumours.

30
Assess History

• Snoring
• Apnoea
• Stridor
• Inspiration (extrathoracic e.g laryngomalacia)
• Expiration (intrathoracic)
• Blue
• Hoarse
• Daytime somnolence?
• Previous anaesthetic?
• Preferred position sitting?

31
Assess - physical

• Failure to thrive sleep disordered breathing
• Caucasian v African children - UAO
• Dyspnoea
• Chest retractions
• Drooling saliva
• Weak cry
• Dysmorphic facies

32
Additional

• Lung function tests spirometry FEV1
• Radiology
• AP lateral of neck and thoracic inlet
• CT MRI
• Awake Endoscopy
• Anatomy dynamic views
• Sleep studies

33
Anaesthesia

• Inhalational induction technique of choice
• IV occ used but in small doses so spontaneous
  respiration is maintained
• Always secure IV access before attempting
  intubation.
• Neuromuscular blockers best avoided
• Time !!!

34
Difficult intubation

• Is airway secure? i.e oxygenation ventilation
• Is position correct?
• Is roll present? Is it too big?
• Use cricoid pressure
• How long do I attempt it? assistant role!
• How many attempts avoid trauma
• Do I need to intubate? wake up or tracheostomy?

35
Laryngeal mask airway

• Definitive airway
• May be used to ventilate child
• As conduit for fibreoptic intubation
• Temporary airway until surgical airway secured

36
Alternative laryngoscopes

• Mc Coy
• Macintosh
• Seward
• Paediatric video laryngoscope
• Storz Glidescope
• May assist in intubation
• Some reports of benefit
• Early in their use

37
Fibreoptic intubation

• Child must be anaesthetised, oxygenated and
  stable to allow time for intubation.
• ET in nostril or special mask.
• Topical anaesthesia
• 4 lidocaine
• Oral, via nasal ET tube, or via LMA.
• Try to maintain skills.

38
Fibreoptic intubation oral, nasal.

• Load tube onto scope
• Nasoendoscopes 2.2 2.5 mm
• no suction
• should take any size tube.
• Bronchoscopes 2.8 4 mm.
• Can take size 3.5 ET tube.
• Have suction
• May use suction port to deliver local

39
OLCHC Plan

• Inhalational induction IV access
• Anaesthetic intubation
• Intubate with MLB setup (Parsons)
• Rigid bronchoscope bougie
• Maintain airway with mask or LMA
• Tracheostomy

40
Tracheostomy when ?

• Cant intubate
• Can intubate but with much difficulty
• Extubation may cause problem

41
Cant intubate, cant ventilate

• Very rare
• Needs structured protocol to manage

42
Cricothyroidotomy complications

• Pneumothorax
• Surgical emphysema
• Vascular injury
• Haemorrhage
• Haematoma
• False passage

• Aspiration
• Pulmonary barotrauma
• Subglottic oedema
• Subglottic stenosis
• Oesophageal perforation
• Infection

43
Cricothyroidotomy

• APLS/Books percutaneous needle or surgical
  cricothyroidotomy
• In practice trachea may be only mm in diameter
  therefore cricothyroidotomy very difficult

44
Principles for paediatric diff intubation

• Maintain oxygenation ventilation
• Multiple and prolonged attempts at intubation
  cause morbidity therefore limit to 4.
• Blind techniques have a high failure rate and
  cause trauma.
• Awaken patient and postpone surgery?

45
Principles for paediatric cant intubate cant
ventilate scenario

• Use 2 person technique to ventilate
• LMA frequently rescues situation
• If above fail proceed to surgical airway.