2013 Pediatric Fellows Boot Camp_Adjuncts BMV & LMA
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Transcript of 2013 Pediatric Fellows Boot Camp_Adjuncts BMV & LMA
Pediatrics
Matthew Musick, MD
Fellows Boot Camp 2013
Airway Adjuncts, Bag Mask
Ventilation, and Laryngeal
Mask Airways
Page 2
Pediatrics
Objectives
•Be able to choose proper size oral/nasal airway,
facemask (for BMV), and LMA according to
anatomic landmarks and patient age/size
•Learn complications from various airway
maneuvers
‐5 complications related to use of airway adjuncts
‐3 complications related to BMV
‐3 complications related to LMAs
Page 3
Pediatrics
Pediatric vs Adult Airway
Infant Adult
Page 4
Pediatrics
Positioning (“sniffing”)
Page 5
Pediatrics
Positioning - Infant
R
Page 6
Pediatrics
Positioning - Comparison
Page 7
Pediatrics
Obstruction
Page 8
Pediatrics
Options – Chin lift
Page 9
Pediatrics
Options – Jaw Thrust
Page 10
Pediatrics
Options – Oral Airway
Page 11
Pediatrics
Oral Airway
Page 12
Pediatrics
Oral Airway – Too Small
Page 13
Pediatrics
Oral Airway – Too Large
Page 14
Pediatrics
Insertion Technique
•First open mouth (can use cross finger scissor
technique)
•Option # 1 – push tongue down w/ tongue
depressor and insert “straight in”
•Option # 2 – insert “upside down” and then
rotate 180 degrees as oral airway is being
advanced to back of oropharynx
Page 15
Pediatrics
Oral Airway Complications
•Yak*$%! (ie the gag reflex)
•Obstruction (not really your desired effect)
•Laryngospasm
•Tooth/mouth injury
Page 16
Pediatrics
Nasopharyngeal Airways
•Same concept of relieving tongue obstruction
•Better tolerated than oral airway if patient semi-
conscious or awake
•Contraindicated with:
‐Significant facial trauma (esp basilar skull fracture)
‐Severe coagulopathy
Page 17
Pediatrics
Size Selection
Page 18
Pediatrics
Nasopharyngeal Airway Insertion
•Don’t forget the lube!
Page 19
Pediatrics
Bag Mask Ventilation
•True life saving technique
•Can oxygenate and ventilate
•Helpful during intubation
‐Can “improve” patient so that intubation is less
strenuous
‐Can “rescue” patient if intubation attempt fails
•May need airway adjunct and two people!
Page 20
Pediatrics
Equipment
•Self inflating reservoir bag, unidirectional valve,
standard mask connector, oxygen hook-up
‐Manometer, PEEP valve
•Different size masks
Page 21
Pediatrics
Mask Size and Fit
•Extend from bridge of nose to chin (covering
mouth and nose)
•Inflatable rim can help assure seal
•“E-C” hold is preferred technique
‐Thumb and forefinger form C on top of mask
‐Middle/ring fingers on ridge of mandible (chin lift)
‐Pinky behind angle of mandible (jaw thrust)
Page 22
Pediatrics
E-C Hold
Page 23
Pediatrics
Successful BMV
•Chest rise
•Chest rise
•Chest rise
•Increased O2 sats, auscultation, condensation
in mask
Page 24
Pediatrics
Complications of BMV
•Excessive air in stomach
‐Aspiration risk
‐Decreases lung volume/requires higher PIPs
•Corneal abrasions
•Injury to lips/gums and nasal bridge
•Excessive bagging due to user exuberance
Page 25
Pediatrics
Laryngeal Mask Airway
•Many uses/indications for our anesthesia
colleagues
•Rescue airway device in PICU
•Supraglottic airway that can be placed “blindly”
but is temporary in nature
Page 26
Pediatrics
LMA
Page 27
Pediatrics
LMA
Page 28
Pediatrics
LMA Notes
•Size selection is based
on weight – look at
package!
•It will “pop up” slightly
after cuff is inflated if
seated correctly
•Don’t forget the lube
Page 29
Pediatrics
LMA Insertion
•Few methods…
•Forefinger guiding
technique
Page 30
Pediatrics
LMA Insertion
•Rotational method
‐Similar to oral airway rotation
‐“Cuff” is pointed up towards palate
‐After advancing past the tongue, you rotate 180 degrees
Page 31
Pediatrics
LMA Insertion
•Just stick it
in
•Works best
for curved
LMA
Page 32
Pediatrics
LMA Complications
•Aspiration (although much less than
traditionally feared)
•Gagging and possibly laryngospasm
•Difficult to achieve high peak inspiratory
pressures
Page 33
Pediatrics
Questions???