Pediatric Airway Management دکتر مهرزاد آرتنگ رییس اداره اورژانس پیش بیمارستانی دانشگاه 1392/4/1
Pediatric Cardiopulmonary Arrests In most infants and small children respiratory arrest precedescardiac arrest.
Characteristics of Newborn Respiratory System • Infant lung is a unique structure not a mini- adult lung • Airways, distal lung tissue and pulmonary capillary bed continue to grow and develop after birth • Alveoli development complete and adult anatomy by 8-10 years of age • Ossification of ribs and sternum complete by 25 years of age
Nose • Obligatory nasal breathing • Poor tolerance to obstruction • Relatively Large • Neck extension may not relieve obstruction Tongue
Head • Relatively large • Anterior flexion may cause airway obstruction • Relatively large and U- shaped • More susceptible to trauma • Forms more acute angle with vocal cords Epiglottis
Cricoid • Narrowest portion of airway • ↑ resistance with airway edema or infection • Acts as “cuff” during tracheal intubation
Effect Of Edema If radius is halved, resistance increases 16 x
Trachea • Small diameter (6mm), high compliance • ↑ resistance with airway edema or infection • Collapses easily with neck hyperflexion or hyperextension ↑ pulmonary vascular resistance (PVR) Very sensitive to constriction by hypoxia, acidosis and hypercarbia
WOB Regulation of Breathing • Weak resp muscles • Response to ↓ O2/ ↑ CO2 minimal • Tolerates hypoxia poorly
Assessment • 30 second rapid cardiopulmonary assessment is structured around ABC’s. • Airway • Breathing • Circulation
Airway • Airway must be clear and patent for successful ventilation. • Position • Clear of foreign body • Free from injury • Intubate if needed
“Patients do not die from lack of intubation they die from lack of oxygenation”
Cricoid Pressure (Sellick's Maneuver) • Cricoid pressure is indicated in the intubation of those who are deeply unconsciousand in those who have been paralyzedfor intubation.
Breathing • Breathing is assessed to determine the child’s ability to oxygenate. • Assessment: • Respiratory rate • Respiratory effort • Breath sounds • Skin color
Impending Respiratory Failure • Respiratory rate less than 10 or greater than 60is an ominous sign of impending respiratory failure. Prearrest. s
Airway assessment • Best to 1st look from afar. Infants and small children don’t like strangers hard to assess baseline after they are upset. • Is the chest moving? • Can you hear breath sounds? • Are there any abnormal airway sounds ? (e.g.. Stridor, snoring) • Is there increased respiratory effort with retractions or respiratory effort with no airway or breath sounds?
Breathing • RR • Effort • Airway and lung sounds • SpO2
RR • Best to evaluate prior to hands-on assessment • Excitement, anxiety, exercise, pain, fever, agitation can all ↑ RR • ↓ RR with acutely ill child or with ↓ LOC = ++ cause for concern • > 60 in any age is cause for concern • Normals As per PALS
Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Agitation Retractions Access muscles Wheezing Sweating Prolonged expiration Apnea Cyanosis Signs of Respiratory Distress
Normal Wheezes Rales (Crackles) Stridor Rhonchi Pleural Rub Listen on every patient End of Expiration End of Inspiration During both phases Expiration End of Inspiration Lung Sounds
Airway Management • Simple things to improve airway patency • Suction nose and oropharynx • child/ allow child to assume position of comfort • head-tilt-chin lift/ jaw thrust • Use airway adjuncts - NPA/ OPA
Oral & Naso pharyngeal Suctioning • Clean technique • Negative pressure of 80 to 120 mmHg. Test suction level on regulator prior to suctioning • Nasal and oral suction can be performed with same catheter • May result in hypoxia?, ↓ HR (vagal), bronchospasm, larygospasm, atelectasis
هیپوکسی و ساکشن • برای جلوگیری از این مشکل ، ساکشن کردن را به 15ثانیه در بالغین و 5 ثانیه در اطفال محدود کنید .
Oral Pharyngeal Airways (OPA) • Only for use in UNCONSCIOUS pt with no intact cough/gag reflex • Never tape in place
Nasopharyngeal Airways • Can use in conscious/ semi-conscious pt Contraindications: • Basilar skull fracture • CSF leak • Serious midline facial fractures
If these don’t work… • Pt may require more advanced interventions to establish a patent airway • CPAP CPAP uses mild air pressure to keep an airway open. CPAP typically is used for people who have breathing problems …. Continuous positive airway pressure, a particular type of ventilation (breathing) therapy • Intubation • …….
Positionning • If pt has preferred position let them remain in that position e.g. tripod • Repositioning can greatly improve airway patency • Manual airway maneuvers can also help open the airway (head tilt-chin lift/ jaw thrust)
Bag-Mask Ventilation • Indicated when the pt’s spontaneous breathing effort is inadequate despite patent airway • Can provide adequate oxygenation and ventilation until definitive airway control is obtained • Can be as effective as ventilation through ETT
Bagging Units • 3 sizes: Bag-Valve-Mask Components
How much is Oxygen Delivered? 1-Delevery oxygen by pure ambo bag : 16% - 21%
Non-Rebreather Mask • Range 80-95% • Indications • Delivery of high FiO2 • Contraindications • Apnea • Poor respiratory effort • Used at 10 to 15 L/min
Monitor effectiveness of Ventilation • Visible chest rise with each breath • SpO2 • ETCO2 • HR • BP • Pt responsiveness • Air entry on auscultation
If ventilation is not effective… • Reposition pt. Reposition airway. OPA. • Verify proper mask size and placement • Suction airway • Check O2 source and flow • Check bag and mask for function/leaks • Treat gastric inflation
Indications for intubation • Respiratory distress • Apnea • Upper airway obstruction or the potential to develop upper airway obstruction • Actual or potential decrease in airway protection (compromised neurological function) • Inadequate ventilation and/or oxygenation
Preparing for Intubation • Appropriate ETT for >1 yo: (age/4) + 4 Term infant: 3.0-3.5 ID 6 mo: 3.5-4.0 ID 1 yo: 4.0-4.5 ID • Cuffed ETT’s for pt’s > 8 yo • If you anticipate need for high PEEP or PIP (peak inspiratory pressure)may want to use cuffed ETT with <8 yo. Use ½ size smaller ETT. • Remember SOAPME
SOAPME • Suction equipment • Oxygen: O2 flowmeter, preoxygenate 2-3 min, manual resuscitator bag with mask • Airway equipment: ETT, stylet, syringe (cuffed ETT), laryngoscope and blade, lubricating gel, OPA • Position, pharmacy, personnel: supine, rolls for positioning, bed height up • Monitors • ETCO2 detector
Positive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration. The two types of PEEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic PEEP (PEEP caused by a non-complete exhalation). Pressure that is applied or increased during an inspiration is termed pressure support. • Complications • Decrease in systemic venous return • Pulmonary barotrauma can be caused. Pulmonary barotrauma is lung injury that results from the hyperinflation of alveoli past the rupture point. • Increased intracranial pressure — In people with normal lung compliance, PEEP may increase the intracranial pressure (ICP) due to an impedance of venous return from the head. • Renal functions and electrolyte imbalances, due to decreased venous return metabolism of certain drugs are altered and acid-base balance is impeded.