Airway Transport

8/13/2019 Airway Transport

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Airway Management inTransport

Toni Petrillo-Albarano, MD

Pediatric Critical Care Medicine

Childrens Healthcare of Atlanta

at Egleston Childrens Hospital


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Objectives

Overview of the differences betweenthe pediatric and adult airway

Intubation of the pediatric patient


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Anatomic Considerations in

Pediatrics

Relatively Large Occiput

Large Tongue

Larynx is anterior and superior

Epiglottis may be floppy with acuteangle

Narrowest portion is cricoid cartilage


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The Basics

The airway in any patient can be:

Physiologic

maintained easily or with effort by thepatient

Maintainable

with some assistance/positioning

Invasive Intervention

oral airway, nasal trumpet, or intubation


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The Basics

To assist patients in maintaining anairway:

Clear mouth

Position head

Consider Airway adjuncts


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Proper Positioning

A jaw thrust or head tiltmaneuver will position thetongue so that it will notobstruct the airway

Remember that a child has arelatively large tonguecompared to an adult

In infants it is possible tohyperextend the neck too muchand cause the soft tissue toobstruct the airway


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Nasal Trumpet

A nasal trumpet canbe a useful adjunct

possible for thetrumpet to be too longor too short


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Oral Airway

An appropriately placedoral airway will pull thetongue forward andprovide an unobstructedairway

If the oral airway is toolong, it will stimulate agag. If its too short, itwill not lift the tongue.


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Airway Adjuncts

The use of airway adjuncts, such as the nasaltrumpet and oral airway, will only provide an

adequate airway.The patient must have reasonable respiratory

effort.

If the patient is unable to maintain adequateventilation, he/she should be bagged orproceed to endotracheal intubation.


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Indications for Intubation

1. Unable to protect airway

2. Inadequate ventilation

3. Hypoxemic respiratory failure requiringpositive pressure

4. Therapeutic (e.g. Hyperventilation inhead injury)


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Difficult Airway Considerations

Short, muscular neck

Receding mandible

Protruding incisors

Uvula not visualized

Limited TMJ mobilityLimited C-spine mobility


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What do you need?

Monitors -- cardiac and pulse oximetry

Suction -- Yankauer or catheter

Machine -- ventilator or bag/mask

Airway -- Endotracheal tube

Intravenous -- peripheral or central lineDrugs --

sedation/analgesia/paralysis/atropine


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Laryngoscopes

Straight

Curved

Fiberoptic


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Proper visualization

The laryngoscopeshould be used to liftup and out. Do notrock back on upperteeth.

Curved blade tip isplaced in vallecula and

will lift epiglottis awayfrom airway.

Straight blade tip isused to hold the

epiglottis from beneath.


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Proper ETT Size

Newborn - 6 months 3.5

6 months - 1 year 4.0

> 1 year 4 + age

4


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Intubation Procedure

Prepare Equipment

Position patient

Table height Sniffing position

Pre-oxygenate 4 max breath in 30 sec

100% O2 for 3-5 min Induction agent

sedative/analgesic

Neuromuscular

blocker

Intubation Laryngoscope in L hand

Insert on R of mouth and

sweep tongue to L Advance in midline until

epiglottis visualized

Advance tip of blade

into vallecula (curvedblade)

beneath epiglottis(straight blade)

Lift towards feet

up and out, NeverLever


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Rapid Sequence Intubation

Done when immediate airway stabilization isrequired or the patient has a full stomach

has eaten -- pregnancy

trauma -- abdominal mass

GER -- misc

bowel obstruction

Expedited with rapid acting drugs andavoidance of bag mask ventilation


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Rapid Sequence Intubation

Procedure

Pre-oxygenate

Rapid Induction Agents

Rapid Acting Neuromuscular Blocker

Sellicks Maneuver

Intubate Check breath sounds, inflate cuff (if

applicable)

Release cricoid pressure


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Sellicks Maneuver

Cricoid Pressure

Closes esophagus against the vertebralcolumn

protects against passive regurgitation

DO NOT release until airway is secure !


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Intubation Medications

Goals:

Provide adequate intubation conditions

airway easily visualized

patient comfort (not fighting procedure)

Avoid complications

hemodynamic instability

ICP in head injury


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Atropine

Blunts vagal response that can causebradycardia and dries oral secretions

Dose = 0.02 mg/kg (min 0.1 mg)

Adverse effects

tachycardia

mydriasis

atropine flush

disorientation


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Benzodiazepines

Effective in providing anxiolysis andamnesia

Onset and duration vary betweenmidazolam, lorazepam, and diazepam

Dose = 0.1 mg/kg

Adverse Effects include: hypotensionand myocardial depression


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Fentanyl

Sedative/Analgesic

Dose 2-5 mcg/kg

Rapid Onset and short duration -- thusan excellent intubation med

Virtually no CV side effects


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Ketamine

PCP Derivative, Dissociative Hypnotic

Rapid Onset and short duration

Dose = 1-2 mg/kg IV or 2-4 mg/kg IM

Increases HR, and BP and thus may beideal for the patient with shock.

Increases cerebral metabolic rate andICP and thus not a good choice in headinjury or seizure


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Thiopental (Pentothal)

Dose = 2-5 mg/kg

Max Effect in 60 seconds

Sedative Hypnotic that decreasescerebral metabolic rate and ICP

Hypotension and Myocardial Depressionare possible adverse effects


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Etomidate

Ultra short-acting non-barbituratehypnotic

rapid induction of anesthesia withminimal cardiovascular effects

0.2-0.6 mg/kg over 30-60 seconds

Peak effect: 1 minuteDuration of action: 3-5 minutes

Can cause adrenal suppression


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Neuromuscular Blockers

Recommend only rapid acting agents:

Succinylcholine - dose = 1 mg/kg IV

Rocuronium - dose = 0.6-1.2 mg/kg IV

Vecuronium - dose = 0.1-0.3 mg/kg IV

Mivacurium - dose = 0.2 mg/kg IV

Atracurium - dose = 0.2 mg/kg IV


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Recommended IntubationCocktails

Controlled Intubation Fentanyl & Lorazepam or

Etomidate

Vecuronium/Rocuronium

+ Atropine

Head Injury

Pentothal or Etomidate Lidocaine 1 mg/kg IV

Vecuronium

Atropine

Septic Shock Atropine

Ketamine Rocuronium/Vecuronium

Status Asthmaticus Atropine

Ketamine Lorazepam

Rocuronium/Vecuronium

h l


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Physiologic Response toIntubation

Airway Reflexes

Laryngospasm Cough

Gag

Cardiovascular

Reflexes Sinus bradycardia

Tachycardia

Hypertension

Dysrhythmias


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Assessing ETT placement

Direct visualization

ETCO2(digital readout or colorpaper)

Chest rise

Auscultation (be certain to confirmabsence of gastric breath sounds)

ETT vapor (unreliable)

Chest X-ray


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Monitoring on Transport

Physical Exam

EKG monitorPulse oximeter

ETCO2Monitor

Reevaluate Frequently


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CapnogramsNormal

Zero baseline

Rapid, sharp up rise

Alveolar plateauWell-defined end-tidal

Rapid, sharp down stroke

AB DeadspaceBC Dead space and alveolar gasCD Mostly alveolar gasD End-tidal pointDE Inhalation of CO2free gas


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CapnographySudden loss of waveform

Esophageal intubation

Ventilator disconnect

Ventilator malfunction

Obstructed / kinked ETT


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CapnographyDecrease in waveform

Sudden hypotension

Massive blood loss

Cardiac arrest

Hypothermia

PE

CPB


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CapnographyGradual increase in waveform

Increased body temp

Hypoventilation

Partial airway obstruction

Exogenous CO2source (w/laparoscopy/CO2inflation)


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CapnographySudden dropnot to zero

Leak in system

Partial disconnect of system

Partial airway obstruction

ETT in hypopharynx


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CapnographySustained low EtCO2

Asthma

PE

Pneumonia

Hypovolemia

Hyperventilation

40

30

Low ETCO2, but good plateau


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CapnographyCleft in alveolar plateau

Partial recovery from neuromuscularblockade

40


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CapnographyTransient rise in ETCO2

Injection of bicarbonate

Release of limb tourniquet

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CapnographySudden rise in baseline

Contamination of the optical bench

need to recalibrate

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Questions

1. Which drug is not used in theintubation of a head injury patient?

A. Ketamine

B. Thiopental

C. Lidocaine

D. Etomidate


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Question

2.Capnographrepresents

A. Esophagealintubation

B. Ventilatordisconnect

C. Obstructed /kinked ETT

D. All of the above


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Question

3. Appropriate ETT size for a 6 year oldcalculated by formula is?

A. 6.0

B. 4.5

C. 5.0

D. 5.5


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Question

4. True or False:

Curved blade tip is placed in vallecula and

will lift epiglottis away from airway


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Question

5. All of the following are indications forintubation except:

A. Unable to protect airway

B. Inadequate ventilation

C. Hypoxemic respiratory failure requiring

positive pressure D. GCS 10

Airway Transport

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