Pediatric Airway Management

1. Pediatric AirwayManagement SNOHOMISH COUNTY EMS

2. OBJECTIVES • Anatomy • Physiology • Equipment • Establish respiratory distress present • Technique • Post intubation management • Pitfalls and Pearls • Difficult airway

3. ANATOMY • Unique <2 years old • Approaches normal adult airway by 8 years old • Glottic opening high and anterior • C1, transitions to C3/4, then C5/6 by adulthood • More soft tissue, less tone

4. Consider copying fig 20-2 p 270 here

5. ANATOMY • Large tongue in relation to oral cavity • Large tonsils and adenoids that can bleed (no blind nasotracheal intubations) • Angle of epiglottis to laryngeal opening more acute

6. ANATOMY • Large occiput/cranium flexes the neck • Avoid further neck flexion • Use sniffing position • Neck flexed, head extended

8. ANATOMY • Small cricothyroid membrane • <3-4 years old almost nonexistant • >8 similar to adults • No surgical cricothyroidotomy <8 • Cricoid ring most narrow part of airway (below vocal cords)

9. PHYSIOLOGY • Smaller floppy upper airway more likely to obstruct and more susceptible to swelling • Resistance is inversely proportional to radius • R  1/r4th power • Small decrease in airway size=large increase in airway resistance

10. PHYSIOLOGY • Crying increases the work of breathing 32 times • Basal O2 requirement 2x that of adults • FRC (functional residual capacity) 40% of adults • Only half the alveoli of adults • Overall, less reserve and faster desaturations

11. EQUIPMENT • Length based systems • Decrease errors • Eliminate remembering and completing mathematical equations • Organize equipment

12. BROSELOW SYSTEM

14. EQUIPMENT • Self inflating bags smallest 450ml • Pop off valves that may have to be closed • Newborn equipment different than peds (0 blades, <50mm oral airways, 250ml BVM, 3-0 tubes)

15. RESPIRATORY DISTRESS • Rapid 30 second assessment • T one • I nteractive • C onsolablity • L ook/track • S peech/cry

16. RESPIRATORY DISTRESS • Altered mental status • Nasal flaring • Head bobbing • Accessory muscle use • Grunting

19. RESPIRATORY DISTRESS • You must undress the patient • Retractions • Substernal • Intercostal • Supraclavicular • Suprasternal

20. RESPIRATORY DISTRESS • Infants are nose breathers • Secretions can impeded air flow • Bulb syringe nasal suction may alleviate this

21. RESPIRATORY FAILURE • Impending respiratory arrest • All of the above signs diminish • Respiratory rate diminishes • Mental status diminishes • Child becomes quiet • Mottling may develop

22. TECHNIQUEMEDICATIONS • Succinylcholine • Dose higher at 1.5mg/kg • Etomidate • 0.3mg/kg • Fentanyl • 1-3mcg/kg consider for age >10 and head injury

23. TECHNIQUEMEDICATIONS • Vecuronium • 0.1mg/kg • Rocuronium • 1mg/kg

24. TECHNIQUE MEDICATIONS • Atropine • Routine use not recommended • Should be available and prepared in case it is needed (more common in children <1) • 0.02mg/kg

25. TECHNIQUE HEAD POSITION • Sniffing position • Slight anterior displacement of neck (pulling chin up) • Small infants may require elevation of shoulders with a towel to counteract a large occiput flexing head • Older children may require a towel under the head • Goal is to align ear canal anterior to shoulders • Head tilt chin lift or Jaw thrust (trauma patients)

26. Picture Fig 21-1 page 284

27. TECHNIQUE OXYGEN SUPPLEMTATION • Oxygen may be delivered by • Blow by • Nasal cannula • Face mask • Forcing the child to struggle with nasal cannula oxygen increase oxygen demand • Blow by may suffice

28. TECHNIQUE BVM • BVM alone may suffice for short transports • Pediatric airway obstruction usually amenable to BVM • The extra thoracic trachea is collapsible in children, so with increased negative pressure from inspiration during obstruction, obstruction may become worse and BVM may help

29. TECHNIQUE BVM • Don’t compress submental tissue • Hold angle of mandible • Use C-Clamp technique (solo) • Use 2 providers when possible • Don’t put pressure on eyes (causes vagal response)

31. TECHNIQUE BVM • Normal tidal volume 8-10ml/kg • Watch for adequate chest rise • Squeeze-Release-Release to allow for exhalation • Only use enough force to see chest rise • 8-10 BPM code, 12-20 alive (monitor end tidal CO2)

32. TECHNIQUE BVM • Avoid gastric insufflation • Avoid excessive peak inspiratory pressure • Ventilate slowly and watch for chest rise • Slight cricoid pressure (excessive will compress trachea in peds)

33. TECHNIQUE BLADES • Follow Broselow guide • Miller straight blade better until about age 5 • Lifts disproportionately large epiglottis out of way

34. TECHNIQUE CRICOID PRESSURE • Insufficient evidence to routinely recommend cricoid pressure during intubation (as opposed to BVM)

35. TECHNIQUE LAYNGEAL MANIPULATION • Use as needed • Frequently: • B ackward • U pward • R ightward • P ressure

36. TECHNIQUE TUBES • Use Broselow guide • Be prepared with tubes 0.5mm larger and smaller • Narrowest part of airway is below cords • If tight, use smaller tube • If large air leak, use larger tube or same size tube with cuff • Small air leak, no worries if adequate chest rise, O2 sat, end tidal CO2

37. TECHNIQUE TUBES • Cuffed tubes • Are OK • Cuff pressure needs to be monitored (20-25cm water) • Don’t have to be inflated • In general, go a size smaller if using cuffed tube for size <6.0 • Too large a tube/too high cuff pressure)=laryngeal tracheal stenosis which can develop rapidly

39. TECHNIQUE TUBES • Tube insertion depth • Follow Broselow • 3x size of tube (4.0 ETT=12cm insertion length at teeth) • Secure tube, immobilize neck, as short trachea predisposes to moving tube too far in with neck flexion, and out with neck extension

40. TECHNIQUE CONFIRM PLACEMENT • Tube fogging • B/L breath sounds • Silent epigastrum • End Tidal CO2 • Pulse ox

41. TECHNIQUE END TIDAL CO2 • Peds detectors up to 15kg (adult detectors have too much dead space in circuit) • Adult detectors over 15kg (peds detectors will cause too much resistance

42. TECHNIQUE END TIDAL CO2 • In cardiac arrest: • If <10-15mmHg, focus on improving CPR and avoid over ventilation • An abrupt and sustained increase may signal return of spontaneous circulation • In non arrest: • Titrate to clinical condition (35-45 unless head injury/impending herniation 25-30)

43. POST INTUBATION MANAGEMENT • Adequate sedation • Benzodiazepines • Diazepam 0.2mg/kg (max 10mg/dose) • Lorazepam 0.05mg/kg (max 2mg/dose) • Midazolam 0.1mg/kg (max 2mg/dose) • Opiates • Fentanyl 1-3mcg/kg (max 50mcg/dose) • Morphine 0.05-0.2mg/kg (max 5mg/dose) • Paralytics as needed • Rocuronium 1mg/kg • Vecuronium 0.1mg/kg

44. POST INTUBATION MANAGEMENT • Problems • D isplacement of tube (confirm placement) • O obstruction of tube (pass suction catheter) • P neumothorax • E quipment failure (unhook from vent, check O2)

45. PITFALLS AND PEARLS • Performance anxiety • Equipment stocking and testing • Troubleshooting • Periodic training and practice

46. DIFFICULT AIRWAY • Infectious disease causes • Noninfectious causes including trauma • Congenital abnormalities

47. DIFFICULT AIRWAY INFECTIOUS DISEASE • Epiglottitis • Croup • Retropharyngeal abscess • Bacterial Tracheitis • Ludwig’s angina

48. DIFFICULT AIRWAY INFECTIOUS DISEASE • Small changes in airway diameter have a large impact on airway resistance • Crying increases work of breathing 32 times • Don’t “over treat”

49. EPIGLOTTITIS • If stable, leave patient with parent in position of comfort • 2 person bag valve mask ventilation can be sufficient • If needed, intubation can be attempted with a smaller than predicted tube • Push on chest to try to see bubbles coming from airway if visualization obstructed • One of the few indications for needle cricothyrotomy if all else fails