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Pediatric Airway Management4- Differently Shaped Epiglottis
Infant epiglottis ohmega () shaped and angled away from axis of
trachea
More difficult to lift an infant’s epiglottis with laryngoscopic
blade
5- Funnel shaped larynx
Narrowest part of infant’s larynx is the cricoid cartilage:
Tight fitting ETT may cause edema.
Uncuffed ETT preferred for patients < 8 years old
The only complete ring
Recently, the concept of the child having a funnel-shaped airway
with the cricoid as the narrowest portion of the airway has been
challenged. Based on bronchoscopic images,
Dalal and colleagues (2009) suggest for infants and children the
glottis, not the cricoid, may be the narrowest portion.
Five Cardinal Anatomical Features of Infant’s Larynx
1- Higher Larynx
Acute angulation between plane of tongue & plane of glottis
makes exposure difficult straight blade exaggerated by mandibular
hypoplasia (Pierre Robin syndrome).
Positioning
3- Anteriorly Angulated Vocal Cords:
The anterior attachment of vocal cords are lower than posterior
attachment difficulty in nasal intubations where “blindly” placed
ETT lodges in the anterior commissure rather than in the
trachea.
Respiratory Physiology Obligate nasal breathers
Immaturity of coordination between respiratory efforts and
oropharyngeal motor/sensory input.
During quiet respiration, the tongue rests against the roof of the
mouth.
Respiratory Physiology Respiratory Parameters
Tidal volume (6-7 ml/kg/min)
High respiratory rate (40-60 breaths/min)
High alveolar ventilation (130 ml/kg/min)
Lung compliance is less while chest wall compliance is more than
those in adults {reduced FRC and atelectasis} PEEP.
Respiratory Physiology Effect of Edema on WOB
Laryngoscope Blades
Straight Laryngoscope Blade – used to pick up the epiglottis
Intubation - Positioning
OA/PA/LA
Trauma positioning
Externally
Internally
ET Tube sizes
Newborn 3.5 3.5 9
Children > 2 years:
Equipment choosing
Uncuffed tubes (in mm):
(Age in years/2) + 12
Tracheal Tube Sizes Insufflation Pressure ? Muscle Relaxants?
Insertion length (Alveolar ridge)
Nasopharyngeal Airway
Hazards: long, bleeding 30%, intracranial placement
Techniques to Open the Airway Head tilt- Chin lift - Jaw Thrust –
Oropharyngeal Airway
Aligning of the Upper Airway Axes ( More than 6 Years Old)
Three-axes theory?
Macintoch
Miller
Age
For neonates ≤3 kg and infants ≤1 year, ID 3.0-mm
For children 1 to 2 years of age, ID 3.5-mm
For children ≥2 years, ID (mm) = age/4 + 3.5
Post-intubation croup was 0.4% (2/500 children)
Endotracheal tubes fabricated without the Murphy eye are known as
Magill tubes,
whereas those that have this opening are called Murphy tubes.
However, there are potential disadvantages to the presence of a
Murphy eye on an endotracheal tube, including a tendency for
accumulation of secretions and the possibility that a stylet,
catheter, or bronchoscope may get stuck, requiring the removal of
the entire assembly.
LMA: Reusable Classic, Disposable Unique, ProSeal
Silicone
PVC
Silicone
LMA Sizing
LMA Size
Patient Size
Does not secure airway
Following its blind passage through the oral cavity, the proper
seating of an LMA is generally heralded by a slight rise of the
device when the mask’s cushion
is inflated with air. Care should be taken to use the minimal
effective inflation pressure for the cuff, typically up to 60
cmH2O. The routine use of a manometer is advocated
The more cephalad and anterior position of the larynx of a child as
compared with an adult has prompted the use of an alternate
insertion technique in children. In this case, the LMA is inserted
with its cushion placed against the hard palate. The device is then
rotated through 180 degrees until the cushion is seated at the
laryngeal inlet . This method for the insertion of an LMA appears
to be especially useful in preschool and young school-age
children.
LMA sizes
Patient’s weight
Loose or missing teeth.
Size and configuration of mandible (side view).
Location of larynx in relation to the mandible.
Presence of inspiratory stridor :epiglottitis, croup, extrathoracic
foreign body.
Both inspiratory and expiratory stridor: aspirated foreign body,
vascular ring, or large esophageal foreign body.
Prolonged expiration: lower airway disease?
Baseline oxygen saturation in room air.
Bilateral microtia (ear deformity easily notable) is associated
with mandibular hypoplasia & difficulty in visualizing the
laryngeal inlet (42%) & with unilateral microtia (2.5%).
Are there congenital anomalies that may fit a recognizable
syndrome? The finding of one anomaly mandates a search for
others.
microtia
Wired jaw
Evaluation of the Upper Airway (Diagnostic Testing)
X-ray, MRI and CT.
Radiologic airway examination in a child with a compromised airway
must be undertaken only when there is no immediate threat to the
child's safety and only in the presence of skilled and
appropriately equipped personnel able to manage the airway.
Endoscopic evaluation (flexible fiberoptic endoscopy)
Arterial blood gas analysis (chronic airway obstruction with
respiratory acidosis)
Encephalocele
Scleroderma
Same rules and sizing as LMA
Need special armored tube for intubation
New similar devices exist
Combitube
Regular (over 5.5 feet tall)
Not useful in most kids
Easy to place
Feel tracheal rings
Optimal External Laryngeal Manipulation (OELM)
OELM is particularly helpful for infants & children with
immobile or shortened necks.
Either by an assistant or the laryngoscopist.
Intubation Guides
Intubation through LMA (Blind)
Fibreoptic Intubation through LMA
Failed airway
Failed ventilation
Percutaneous needle cricothyrotomy provides only a mean for oxygen
insufflation and does not reliably provide adequate
ventilation.
If glottic or subglottic pathology is not suspected, LMA placement
to establish ventilation may be appropriately attempted
first.
Cricothyrotomy - Complications
Broselow-Luten Emergency System