PediatricAirwayManagement.07.12.Final

7/31/2019 PediatricAirwayManagement.07.12.Final

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Pediatric Airwaymanagement

Alfredo Castellanos, MDMiami Childrens HospitalCICU FellowPGY-7


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Objectives

Anatomy and Physiology

Airway Assessment

Basic Life Support Oxygen Support

Airway Adjuncts

Intubation Cricothyroidotomy

Conventional Mechanical Ventilation


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Children are not small adults

Size

Shape

Position


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Metabolism

Higher BMR in infants

Higher RR/Ventalitory Requirement

Higher O2/CO2 Production

Smaller FRC

Quicker desaturation/decompensation


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Airway Assessment

History

Medical/Surgical

Duration/Character

Associations

Infections

Foreign-body

Aspiration/choking episodes

Medications

Last Meal


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Airway Assessment

Physical

Observation

Auscultation

Vital Signs

Radiologic


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Airway

Head tilt-chin lift Jaw thrust


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Breathing


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Oxygen

q Masks

o Venturi

o Nonrebreather

o Simple


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Oxygen

q Cannula

o Nasal

o High flow

q Hoods


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Nasal Airway


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Nasal Airway


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Oral Airway


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Bag Mask Ventilation


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Bag Mask Ventilation


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LMA


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LMA

Weight (kg) LMA Size Inflation Vol(5x the size)

< 5 1 5

5-10 1.5 7.5

10-20 2 10

20-30 2.5 12.5

>30 3 15


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Intubation

Indications

Respiratory/Cardiac Arrest

Upper Airway Obstruction

CNS Injury/GCS 8 or less

Neuromuscular Weakness

Respiratory Distress

Hemodynamic Instability

Drug Administration

Elective- Procedure, Surgery


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Intubation

Preparation

AMPLE

Bag-mask, pressure gauge, PEEP valve

O2 source

Laryngoscope, blade

Suction equipment

Stethoscope

MOUTHS


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Intubation


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Intubation

Preparation

ET tube +/- cuff, stylet, syringe, lubrication

Age Kg ETT Length

NewBorn 3.5 3.5 9

3 month 6 3.5 10

1 year 10 4.0 11

2 year 12 4.5 12

Children > 2 years:ETT size: (Age+16)/4ETT depth (lip): ETTsize x

3


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Intubation

Cuffed vs Uncuffed ETT

2005 AHA Pediatric and Neonatal BLS

Airway Cuff Pressure

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) an. American Heart Association.Pediatrics. 2006 May;117(5):e989-1004.PMID: 16651298[PubMed - indexed for MEDLINECuffed vs non-cuffed endotracheal tubes for pediatric anesthesia.Weber T, Salvi N,Orliaguet G, Wolf A. Paediatr Anaesth. 2009 Jul;19 Suppl 1:46-54. Review. No abstract

available. PMID: 19572844 [PubMed - indexed for MEDLINE]
http://eresources.library.mssm.edu:2060/pubmed/16651298http://eresources.library.mssm.edu:2060/pubmed/16651298http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/19572844http://eresources.library.mssm.edu:2060/pubmed/16651298http://eresources.library.mssm.edu:2060/pubmed/16651298


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Intubation

Preparation

CO2 indicator/monitor

Sedatives/analgesia/muscle relaxants/atropine

Cardiopulmonary monitor

Neck roll for > 2 years old

Tape/adhesive solution/securing device

Assistant- Assign

Ventilator


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Intubation

Technique

Insert laryngoscope into the right mouth

At the tonsillar pillars sweep Tongue to midline

Extend blade over base of Tongue and

Curved blade: tip into vallecula

Straight Blade: tip over the epiglottis


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Intubation


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Intubation

Technique

Exert traction upward along axis of handle

Do not use teeth or gums as a fulcrum

Results in significant oral/dental trauma

Insert ET Tube from the right corner of mouth

Avoids obstructing view

Cricoid pressure may facilitate glottisviewing

Position ET Tube

Black marker on ET Tube at level of cords


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Intubation


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Intubation

Assess Tube Position

Symmetrical Chest Movement

Auscultate for equal breath sounds

Document absent breath sounds over stomach

Vapor condenses on inside of tube withexhalation

Oxygen Saturations

Chest X-ray

End-tidal carbon dioxide (required by new

guidelines)


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Intubation


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Intubation

Trouble-Shooting Inadequate Ventilationor Oxygenation

Mnemonic: DOPE

Dislodged tube

Obstructed tube

Pneumothorax

Equipment failure


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Intubation

Difficult

Intubation

Congenital and


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Intubation

Difficult Airway Syndromes

Treacher-Collins

Pierre-Robin

Goldenhaars

Mucopolysaccharidosis

DownsEdwards

Cri du chat


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Intubation


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Cricothyroidotomy


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Ventilator Management

Common terms

RR

PIP

PEEP

TV, TVi, TVe

IT

FiO2

Compliance

MV


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Modes

SIMV

AC

PCVR

IMV

PS

CPAP


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SIMV

Most common mode in pediatrics

Ventilator senses patients breath and tries to

synchronize the breath

Allows spontaneous breathing betweenpositive-pressure breaths

Pressure Control or Volume ControlPS for non assisted breaths

Allows patient to do some work of breathing


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Assist Control

More Commonly used in adults

All respiratory breaths are assisted

Controlled Ventilation-Baseline RR and TV

Will give full assisted breath over baseline RR

Patient does no work of breathing


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PRVC

TV is set as goal amount

Inspiratory pressure of each breath is

automatically adapted to the dynamicconditions of the patients chest and lungmechanics

Pressure varies with a peak pressure limit

included to reduce lung trauma and use onlythe minimum pressure required to deliver thegoal tidal volume

breaths ventilator-initiated or patient-initiated

This mode combines the advantages of volume


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NAVA

Neurally Adjusted Ventilatory Assist

Senses electrical activity of thediaphragm

Synchronizes ventilatory breaths withdiaphragm activity

Improves triggering and ventilatory

response time Improved synchrony

Lung protection

Improves patient comfort


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CPAP

Delivers constant pressure

Similar to continuous PEEP

No additional assistance above the baselinepressure

Patient needs to be spontaneously breathing


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Ventilator Strategies

Oxygenation

Affected by O2 concentration and perfused

alveolar surface area

FiO2 will increase O2 Concentration

PEEP will maintain end-expiratory pressure abovealveolar closing pressure thus preventing

atelectasis and also increase MAP which can leadto further alveolar recruitment

IT can be shortened to allow longer Inspiratorytimes


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Ventilator Strategies

Ventilation

MV= RR x TV

Increasing RR or TV/PIP will improve Ventilationand decrease pCO2

With air trapping, Increased RR will not improvepCO2

If end-inspiratory pressures are greater then 30cm H20 then must weight risk of volutrauma

ARDS-permissive hypercarbia


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Initial Vent settings

FIO2

start at 100%, once stable wean towards 50% or

lessDetermine your goal SaO2 and wean to maintain

Depending on the severity of illness, 100%maybe needed


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Initial Vent Settings

PEEP

Physiologic 3-5 cm H2O

May need higher to maintain adequateoxygenation

ARDS/Asthma

RREstablished initially based on patients age or

illness

Obtain Blood gas and adjust accordingly

Low vs High RR


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IT

Based on I:E ratio

1:2 for infants and preschool children

1:2.5 for school age and adolescents

TV

6 to 10 cc/kg

Note the PIP generated for desired TV

If > 30cm H2O, consider changing TV or go to PC


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PIP

Enough to move the chest and get adequate TV

12-15 cm H2O above Peep in a patient withoutsignificant lung disease

Obtain a gas and adjust accordingly

PIP greater the 30 to 35 cm H2O, must beweighted against risk of volutrauma


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PediatricAirwayManagement.07.12.Final

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