Pediatric Otolaryngology for Anesthetists followed by the delightful Airway Disorders in Infants and Children Andrew M. Shapiro, MD Private Practice, Pediatric Otolaryngology Clinical Associate Professor of Surgery Pennsylvania State University College of Medicine
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Pediatric Otolaryngology for Anesthetists followed by the ...€¦ · Pediatric Otolaryngology for Anesthetists followed by the delightful Airway Disorders in Infants and Children
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Pediatric Otolaryngology for Anesthetistsfollowed by the delightful
Airway Disorders in Infants and Children
Andrew M. Shapiro, MDPrivate Practice, Pediatric Otolaryngology
Clinical Associate Professor of SurgeryPennsylvania State University College of Medicine
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
What does a pediatric otolaryngologist do?
Inflammatory, congenital and neoplastic disorders involving the head and neck
Simple surgeries in fairly healthy kids Big surgeries in fairly healthy kidsSimple surgeries in sick kidsBig surgeries in sick kids
Ear surgeryNasal and sinus surgeryAirway surgeryPharyngeal surgeryCraniofacial surgeryTumors and congenital anomalies of the head and neck
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
OrganizationEmphasize that there are distinct qualities required when caring for childrenUnderstand the anesthetic implications of otolaryngologic surgeryUnderstand special situations and patient circumstancesReview significant ENT airway conditions
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Evolving psychological status must be appreciated from neonates to adolescentsDental
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Characteristics of Pediatric Otolaryngology Patients
“Healthy” PedENT patients are often “sick” on the day of surgery
Congestion, runny nose, cough“a case cancelled is not a case done”
“Sick PedENT patients tend to have chronic lung disease from prematurity, aspiration, cystic fibrosis, or reactive airway disease
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Points of convergenceThe surgeon and the anesthetist are a TEAM (and I’m not just saying that!)Maintain good surgical access while preserving the ability to sustain ventilation (or vice versa)
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Otologic CasesMyringotomy and tube insertions
Most common procedure under GA Mask anesthetic
Older children may benefit from IV/LMAPremed? Narcotic?
Tympanoplasty/tympanomastoidectomyNo muscle relaxant during procedureNo nitrous oxideSecure tubes and IV’s; lots of “turning” during case
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Nasal and Paranasal sinus surgeryExpect secretions and bloodExpect a generous helping of vasoconstrictors
Control blood pressureExpect a “touchy airway”
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Anatomic ClassificationSupraglottic
NoseChoanal atresiaNOWCA
Craniofacial DysmorphologyPierre Robin SyndromeTreacher collinsApertsCrouzonsMoebius
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Cross Sectional Airway Diameter
Adult1mm edema = 81% of normal area
Term Newborn1mm edema = 44% of normal area
20mm
5mm
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Clinical presentationFailed extubation attempts in NICUStridorRecurrent croupProgressive respiratory failure with stridorFeeding difficultiesFailure to thrivePersistent coughTracheotomy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
EvaluationHistory
Details of extubation attemptsPresence, absence, and characteristics of stridor
Onset/Progression Impact of position
Nature of cryFeeding abnormalitiesPrior airway interventionsCardiopulmonary statusTerm or prematureApgarBirth weight/weight gainOther medical problems
Physical examinationImagingEndoscopy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
EvaluationHistory
Physical examinationComplete head and neck examination
Changes with position, activityCry/VoiceAuscultation of chest
ImagingEndoscopy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
EvaluationHistoryPhysical examination
ImagingHi KV AP and Lateral plain filmsAirway flouroscopy/Barium SwallowMRI in patients with suspected vascular/mediastinal pathologyEndoscopy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
EvaluationHistoryPhysical examinationImaging
EndoscopyFlexible
Need for sedation and inability to control airway and ventilation Useful for proximal airway evaluation at bedside or as outpatientDistal airway evaluation in intubated patients
RigidSpontaneous ventilationMicrolaryngoscopy
• Webs, glottic scarring, interarytenoid adhesions, fixation or paralysisSubglottis
• Size, maturity, length, stomal siteRemainder of tracheobronchial treeSizing of airway
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Airway Endoscopy-Stages1. Preparation and
Communication a) Equipmentb) Monitoring
2. Induction3. Diagnostic Laryngoscopy and
topical anesthetic4. Diagnostic Suspension
laryngoscopyControlled airway for microscopy or bronchoscopy
and Diagnostic Bronchoscopy5. Therapeutic intervention
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Anesthesia for airway endoscopyClear communication essentialAvoid jet in young childrenTechniques
Apneic techniqueSpontaneous ventilation in young children
Topical anesthetic?In older children (5 -10 years) relaxant with controlled ventilation
NEVER ABOLISH SPONTANEOUS RESPIRATION UNLESS AN ALTERNATIVE AIRWAY IS ASSURED
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Anesthesia for Laser EndoscopyAssure patient and staff protection
Have a fire “plan of action”Minimize FiO2Avoid adding fuel to the fire when possible
Endotracheal tubes/packsApneic ventilation
Relaxant extends working time, accuracy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Anatomic ClassificationSupraglottic
NoseChoanal atresiaNOWCA
Craniofacial DysmorphologyPierre Robin SyndromeTreacher collinsApertsCrouzonsMoebius
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Nasal DisordersChoanal Atresia
Obstruction in posterior nasal cavity90% bony, 10% membraneousBilateral in 40%; other congenital anomalies in 50%Failure to pass #6 catheterUnilateral- observeBilateral
Oral airway; gavage; repair; tracheostomy
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Break time!
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Laryngeal Disorders
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
LaryngomalaciaMost common cause of stridor in neonateEtiology: collapse of supraglottic structures into airway lumen, creating turbulent flow and obstructionIdiopathic--Anatomy vs. innervationGERD relationship (suck swallow dyscoordination)Coarse, non musical inspiratory stridor during first few weeks of life
Accentuated by supine position, feedingCry is normal
Acute airway obstructionTE fistula may allow some ventilationTracheostomy is lifesavingPolyhydramnios may provide a clue, allow for preoperative preparation
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Laryngeal CystCongenital saccular cyst
25% of laryngeal cystsObstruction of sacculewith accumulation of mucus
Vallecular cystSubglottic cyst
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Subglottic hemangioma1.5% of congenital airway anomalies
Female 2:1 Male. ½ with cutaneoushemangiomataUsually asymptomatic at birth, rapid growth after 2 months through 12 monthsSymptoms mimic recurrent croup
Treatment optionsObservation, tracheostomy, steroids (systemic and local), interferon, surgical excision
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Recurrent Respiratory PapillomatosisHPV 6,11Entire respiratory tractInfancy through adultNo cureSurgical therapy, medical adjunctVaccine holds promise
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Subglottic stenosisCongenital
RareIncomplete recanalizationMore mild
Elliptical cricoid
AcquiredMost common1-8% of intubated neonatesOther causes
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Subglottic Stenosis – the recipeCongenital subglottic stenosisGERDInfectionNasogastric tubeETT size and propertiesMovement of ETTReintubationsDuration?
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
StagingClassification from to
Grade I No obstruction
50%
Grade II 51% 70%
Grade III 71% 99%
Grade IV No lumen
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Evaluation:GER/GERD, GLPR/GLPRD
GER is common in children with subglottic stenosis and usually asymptomatic
GER/GLPR likely exacerbates SGS and compromises repair No gold standard to differentiate GER and GERDDual pH probe:
50% of candidates have upper probe pH<4 more than 1% of the timeMajority had no symptoms
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Evaluation: Swallowing Dysfunction Increased risk of aspiration postoperativelyRely on history
Videoflouroscopic examinationLimited in patients with food aversion or congenital aerodigestive anomalies
FEES
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Tracheotomized patients reactive larynxAge/weight/pulmonary status/neurologic disease/aspiration potential/craniofacial or systemic abnormalities
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Endoscopic ManagementMild SGS
May be required following open repair techniquesTechniques
DilationCO2 laser
wedge resections
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
TracheotomyTemporizing measure
Allows for growth prior to definitiveprocedure
Time for improvement of BPDFacilitates dischargeGold Standard?
Mortality rate varies with degree of obstruction above stomaImpairment of speech and language skillsNursing/childcare issues
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
History of airway reconstruction 193O’s
Chevalier Jackson recognizes that many children with laryngeal stenosis do not outgrow their obstruction –permanent tracheotomy was treatment of choice
1960’sMcDonald and Stocks: long term intubation for the management of prolonged ventilatory support in newbornsGreater survival potential of premature newbornsShift of subglottic stenosis from older children and adults to premature infants
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
History of airway reconstructionIncreased incidence of subglottic stenosis recognizedTreatment consisted of repeated dilations
Dogma was “never divide the larynx” to avoid growth disturbance1956 Rethi Expansion of larynx and trachea with long term stent1970’s Fearon and Cotton: Pedicled thyroid cartilage grafts1980’s Free cartilage grafts allow for posterior and anterior grafting1993 First series of successful cricotracheal resections reported
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Cricoid SplitOverviewIndications
Acquired subglottic stenosis in neonate (>1500g) without significant coincidental airway or pulmonary disease<30%FiO2, <35mm Pressure, no vent support
Surgical techniqueOutcomeComplications
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Late PostoperativeVoice problemsEpiglottic/arytenoid collapseWebTracheocutaneous fistula
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Tracheal AnomaliesTracheomalacia
Abnormal flaccidity of trachea leading to collapse on expiration
Collapse of greater than 20% on endoscopy (spontaneous ventilation)Primary vs secondary
MRIRarely occurs with laryngomalacia
Rx: Mild- typically improves within 1-2 yearsReflux therapySevere – tracheostomy with PPVSurgical correction varying success
Stent placement (internal or external)Segmental resectionCartilage grafting
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Tracheal DisordersTracheal Stenosis
Congenital vs. acquiredSymptoms depend upon severity and lengthComplete tracheal ringsBiphasic or expiratory stridor, wheezing, failure to thrive, bronchiolitis, cough recurrent croupVery gentle endoscopy!Rx:
conservative for mild cases; resolution with growthSevere cases: segmental resection vs. anterior split with perichondrial grafting vs slide tracheoplasty or homograft tracheal transplantation
Complications: granulation tissue at anastamotic site
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
Tracheal DisordersVascular Compression
3% of population with anomalies of great vessels
Rarely result in airway obstructionRings vs slingsDouble aortic arch most common ringInnominate artery most common slingRight aortic arch with aberrant left subclavianBarium swallow and MR are essential
0ct 06 Airway Disorders in Neonates Andrew Shapiro, MD, FAAP
ConclusionsDiagnosis of airway disorders in the neonate requires a comprehensive and systematic approachStridor is not a diagnosis, but a symptom: the characteristics will help localize the sourceTwenty five years ago – once a trach, always a trach
Now, almost all tracheotomy dependent children with airway obstruction can eventually be decannulated
Important to have a bag of tricks, as different approach works in different patientslist of options for restoration of the pediatric airway continues to expand