Pediatric Airway-Basics and Beyond - ORANA Annual Conference... · 10/7/12 1 Pediatric)Airway-You)Swallowed) What? StaciKothbauer,CRNA,MS,APNP) University)of)Wisconsin)Hospital...

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Pediatric Airway-‐You Swallowed What?

Staci Kothbauer, CRNA, MS, APNP

University of Wisconsin Hospital American Family Children’s Hospital

Madison, WI

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*  Understand basic pediatric airway anatomy and how it differs from adults *  Identify common syndromes associated with a pediatric difficult airway *  Describe techniques to manage a difficult airway *  Identify risk factors for airway complications during a general anesthetic in the pediatric patient *  Identify common airway emergencies that may present management challenges

Objectives

Pediatric airway anatomy

*  Tongue-‐large in proportion to oral cavity *  Position of larynx-‐higher in neck (C3-‐4) peds vs

(C4-‐5) in adults

Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.237-‐248). Philadelphia: Saunders Company.

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*  Epiglottis-‐large, floppy, and angled away from axis of trachea



* Subglottis-‐narrowest portion of larynx is cricoid cartilage


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* Vocal Cords-‐lower attachment anteriorly * Axis of VC is perpendicular to the trachea


*  Cuffed vs Uncuffed ETT *  Cuffed ETT-‐(age/4) +3 *  Uncuffed ETT-‐(age/4) +4 *  Distance-‐(age/2) +12 *  Leak at 20-‐30 cm H20 * May want to consider uncuffed in infants with anticipated prolonged intubation


Pediatric airway

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Microcuff ETT

Pediatric airway

*  Complications of intubation *  Post-‐intubation croup * ETT to large * Surgery > 1 hour * Repeated attempts * Traumatic intubation * Age 1-‐4

Wheeler, M, Cote, C, J, & Todres, D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.253-‐254). Philadelphia: Saunders Company.

* Position other than supine * Change in position during procedure * Coughing on ETT * Previous history of croup

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Pediatric syndromes

* Pierre Robin * Mandibular hypoplasia * Direct visualization may be difficult, if not impossible


Pediatric syndromes

*  Achondroplasia *  Difficult intubation * Midfacial hypoplasia *  Small nasal passages and mouth * Megacephaly


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Pediatric syndromes

* Marfan syndrome *  Difficult intubation *  Narrow palate or high arched palate *  Scoliosis or kyphosis *  Cardiac and pulmonary disease *  Dissecting aortic aneurysm


*  Rheumatoid Arthritis *  Limited TMJ mobility *  Hypoplasic mandible *  Cricoarytenoid arthritis with narrow larynx *  Cervical spine subluxation, rigid cervical spine


Pediatric Syndromes

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Pediatric syndromes

*  Scleroderma *  Extensive scarring of

mouth, face and body *  Difficult intubation *  Decreased pulmonary

compliance *  Chronic steroid use


Pediatric syndromes-‐Treacher-‐Collins

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Pediatric syndromes

*  Trisomy 21 (Down’s syndrome) *  Small mouth *  Small mandible *  Large, protruding

tongue *  Cervical spine

subluxation *  Consider ½-‐1 size

smaller ETT Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.274-‐278). Philadelphia: Saunders Company.

Pediatric syndromes

*  Turner syndrome *  Narrow maxilla *  Small mandible *  Short neck *  Difficult intubation *  Associated cardiac

disease *  Hypertension


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*  Awake vs Asleep *  Asleep *  Spontaneously breathing * Helpful in locating glottis * Avoid neuromuscular blockade

*  Sedation-‐if tolerated *  Midazolam (0.05 mg/kg IV) and fentanyl (0.5-‐1 mcg/kg IV)

*  Ketamine (0.25-‐0.5 mg/kg IV) every 2 minutes * Psychomimetic emergence reactions less in children


Management of the Pediatric Difficult Airway

*  Nebulized lidocaine *  Topical spray or jellies *  Translaryngeal lidocaine *  “spray as you go” with lidocaine *  Superior laryngeal nerve block *  Use caution not to deliver toxic lidocaine doses *  5 mg/kg or 7 mg/kg with epinephrine


Anesthetizing the airway

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*  Biggest difference from adult *  metabolic rate *  FRC *  Time from zero 02sat from inspired concentration of 90% to neurological injury *  Adults-‐10 minutes *  Children-‐4 minutes!!!!

Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.263). Philadelphia: Saunders Company.

Unexpected Difficult Airway

*  Laryngospasm *  14% in <6 year olds to 3.6% in >6 year olds (1)

*  Higher ASA score *  Type of airway device used (1-‐4) *  Upper respiratory infection (URI) (5)

(1)  Murat I, Constant I, Maudhuy H. Perioperative anesthetic morbidity in children: a database of 24, 165 anesthetics over a 30-‐month period. Pediatric Anesthesia 2004; 14: 158-‐166.

(2)  Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anesthetic complications in children with respiratory tract infections. Pediatric Anesthesia 2001; 11 29-‐40.

(3)  Tait AR, Malviya S, Voepel-‐Lewis T et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001; 95: 299-‐306.

(4)  Rachel Homer J, Elwood T, Peterson D, Rampersad S et al. Risk factors for adverse events in children with colds emerging from anesthesia: a logistic regression. Pediatric Anesthesia 2007; 17: 154-‐161..

(5)  Flick R, Wilder R, Pieper S et al. Risk factors for laryngospasm in children during general anesthesia. Pediatric Anesthesia 2008; 18: 289-‐296.

Who is at risk for respiratory adverse events?

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*  Bordet et al. in Pediatric Anesthesia (2002) (1) *  <6 years *  Recent RI *  Use of LMA *  Flick et al. in Pediatric Anesthesia (2008) (2) *  130 children with laryngospasm under GA *  Significant association between laryngospasm and

current URI or airway anomaly *  LMA + URI=strong association

(1)  Bordet F, Allaouchiche B, Lansiaux S et al. Risk factors for airway complications during general anesthesia in pediatric patients. Pediatric Anesthesia 2002; 12: 762-‐769.

(2)  Flick R, Wilder R, Pieper S et al. Risk factors for laryngospasm in children during general anesthesia. Pediatric Anesthesia 2008; 18: 289-‐296.

Upper Respiratory Infections

* Croup, bronchitis, bronchiolitis, or pneumonia * Within 4-‐6 weeks * Current or new URI * Dependent on procedure *  Fever * Wheezing * “Wet” cough * Patient history-‐asthma

Ghazal EA, Mason LJ, & Cote CJ. (2009). Preoperative Evaluation, Premedication, and Induction of Anesthesia. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.60-‐62). Philadelphia: Saunders Company.

When to Cancel?

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* How long to postpone? *  Ideally 7 weeks….not practical * Postpone 2 weeks

* Bottom line-‐proceed with caution if asymptomatic

Ghazal EA. Mason LJ, & Cote CJ. (2009). Preoperative Evaluation Premedication, and Induction of Anesthesia. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.60-‐62). Philadelphia: Saunders Company. Orliaguet GA, Olivier G, Savoidelli GL, et al. Case Scenario: Perianesthetic Management of Laryngospasm in Children. Anesthesiology 2012; 116: 458-‐471.

When to Cancel?

*  Chin lift *  Jaw thrust *  Positive pressure *  Propofol *  Succinylcholine (0.5 mg/kg IV) or (3-‐4 mg/kg IM) (1) *  Rocuronium (4-‐5 mg/kg IM) (2) *  Treatment depends on severity of laryngospasm (1)  Orliaguet GA, Olivier G, Savoidelli GL, et al. Case Scenario: Perianesthetic Management of Laryngospasm in Children. Anesthesiology

2012; 116: 458-‐471. (2)  American Academy of Pediatrics, Committee on Drugs. Drugs for Pediatric Emergencies. Pediatrics 1998; 101: e13.

Laryngospasm

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*  Epiglottitis, foreign body, bleeding tonsil *  AIRWAY TAKES PRIORITY OVER “FULL STOMACH” *  Keep spontaneously breathing *  Laryngoscopy under deep volatile agent *  ***KEEP CHILD CALM***

*  Clear communication with ENT surgeon and OR staff PRIOR to induction

Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.767-‐772). Philadelphia: Saunders Company.

Airway Emergencies

*  IV after induction *  Parents into OR ???? *  Induce in sitting position *  IV-‐ 10-‐30 mL/kg of LR rapidly *  Early administration of atropine (10 mcg/kg IV) or glycopyrrolate (10 mcg/kg IV)


Airway Emergencies

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*  Epiglottitis *  Keep child calm *  Inhalation induction in sitting position *  IV, rapid rehydration, atropine (10 mcg/kg) *  Deep intubation *  ETT ½ size smaller *  Unable to intubate trach *  Post-‐op-‐PICU, 24-‐48 hrs.


Upper Airway Obstruction-‐inspiratory stridor, retractions, tachypnea

Foreign Body Aspiration

*  5th leading cause of death in <1 year olds *  May present with wheezing,

cough, and unilateral breath sounds *  Emergency treatment if

symptomatic…OR *  If stable, radiographic exam *  DO NOT INDUCE WITHOUT

ENT SURGEON! Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.774-‐775). Philadelphia: Saunders Company.

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What is the foreign body?

LEGO!

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*  Occurs within 6 hours, or 5 to 10 days post-‐op *  Considered full stomach *  Potential loss of airway *  Hemodynamic compromise *  ***Replace fluid, if possible, and draw Hgb/Hct

Hannallah RS, Brown KA, & Verghese ST. (2009). Otorhinolaryngologic Procedures. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.670-‐671). Philadelphia: Saunders Company.

Tonsil Bleed

*  IV access prior to induction *  Pretreat with atropine (10 mcg/kg IV) or glycopyrrolate (10 mcg/kg IV) *  Induce with ketamine (1-‐2 mg/kg IV) or etomidate (0.3

mg/kg IV), and succinylcholine (1.5-‐2 mg/kg IV)

*  RSI *  Difficulty visualizing VC-‐press on stomach *  Limit opioids *  OG tube prior to extubation Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3rd Ed.), A Practice of Anesthesia for Infants and Children (pp.315-‐330). Philadelphia: Saunders Company.

Tonsil Bleed

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*  Goals: oxygenation, reduce airway obstruction, prevent complications *  RSI if full stomach-‐avoid “light” intubation *  Premed prior to induction *  Opioids, IV lidocaine *  Glycopyrrolate or atropine *  Increase expiratory time to prevent air trapping *  Accept somewhat elevated PaC02 *  Limit peak inspiratory pressure to 40-‐45 cm H2o Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.775-‐). Philadelphia: Saunders Company.

Asthma in Emergency cases

*  Treatment *  Bronchodilator-‐nebulized or metered-‐dose inhaler * Albuterol

*  Beta-‐adrenergic agents * Epinephrine 1:1000 (0.01 mg/kg) SQ every 15 min x3 (max 0.3 mL) * Terbutaline-‐0.01 mL/kg (max 0.25 mL) SQ every 30 min x2 or 0.1 mcg/kg/min, titrate to effect

Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3rd Ed.), A Practice of Anesthesia for Infants and Children (pp.315-‐330). Philadelphia: Saunders Company.

Bronchospasm

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* Corticosteroids * Hydrocortisone 7 mg/kg IV immediately and 7 mg/kg/24hr, divided in 6 doses * Methylprednisolone 2 mg/kg IV immediately and 2 mg/kg/24hr, divided in 6 doses * Dexamethasone 0.3 mg/kg IV immediately and 0.3 mg/kg/24hr, divided in 6 doses

Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3rd Ed.), A Practice of Anesthesia for Infants and Children (pp.315-‐330). Philadelphia: Saunders Company.

Asthma

*  Pediatric airway anatomy is different from that of an adult airway *  Be alert to children with syndromes and the potential for a difficult airway *  Keep the child spontaneously breathing when a difficult airway is suspected *  Proceed with caution with recent URI *  Keep child calm during emergency airway situations *  Avoid “light” anesthesia with asthmatics

Conclusions

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Questions?? [email protected]

Pediatric Airway-Basics and Beyond - ORANA Annual Conference... · 10/7/12 1 Pediatric)Airway-You)Swallowed) What? StaciKothbauer,CRNA,MS,APNP) University)of)Wisconsin)Hospital...

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