2013 Pediatric Fellows Boot Camp_ETI

Pediatrics

Fong Lam, MD

Baylor College of Medicine

Critical Care Medicine Boot Camp

Endotracheal Intubation

Pediatrics

Endotracheal Intubation Objectives

•By the end of this workshop, the learner will be able to:

•Recite at least 3 indications and 5 complications associated with orotracheal intubation

•Derive the appropriate ETT size for orotracheal intubation using a formula and/or the patient’s age/weight/size

•Determine the appropriate sized laryngoscopy blade according to the patient’s age/weight/size

•Name at least 3 anatomic differences between the pediatric and adult airway

Pediatrics

8 MONTH OLD WITH RESPIRATORY DISTRESS

Pediatrics

8 Month Old With Respiratory Distress•Previously healthy male

•Fever (41C) x 2 days with cough

•P 155 R 50 BP 75/40 SpO2 85% on ambient air

•Tired-appearing, grunting, decreased aeration on left

Pediatrics

Assessment and Plan

•Assessment?•Pneumonia

•Plan?•Supplemental oxygen

•Peripheral IV

•IV antibiotics

•IV fluids

•+/- CXR

Pediatrics

Moments Later…

•After being placed on 15 LPM non-rebreather mask

•How much FiO2 does this provide?

•SpO2 now 92%

•Still tired-appearing, grunting, subcostal retractions

•P 170 R 20 BP 70/40

•Now what?•Intubate!

Pediatrics

THE PEDIATRIC AIRWAY

From: respiratory-care-sleep-medicine.advanceweb.com/Article/Building-intubation-skills-and-confidence.aspx

Pediatrics

Differences in Pediatric Airway

From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001

Pediatrics

Children Have Larger Tongues

•Children’s tongues are proportionally larger

•May make it difficult to maneuver the laryngoscope for an optimal view

•Remember to place the blade on the right side of the mouth and move toward the left to move the tongue

Pediatrics



Pediatrics

Large, Floppy Epiglottis

•May be difficult to maneuver with the laryngoscope blade

•The Miller (straight) blade is designed to LIFT the epiglottis (more finesse)

•The Macintosh (curved) blade is designed to be placed in the vallecula and encourage the epiglottis to move

From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012

Pediatrics



Pediatrics

The Funneled Larynx

Adult Infant

Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

•Narrowest point is in the subglottic (below vocal cords) region

•Too tight of an ETT may cause airway edema and stridor post-extubation

Pediatrics



Pediatrics

Pediatric Airways Are More Anterior and Superior Than Adult Airways

Image from: http://depts.washington.edu/pccm/Pediatric%20Airway%20management.ppt

Adult Infant

•This makes proper position vital to the success of intubation

•Common mistakes are:

• Placing the laryngoscope blade too far

• Hyperextension of the neck

•Sometimes, you may need to gently manipulate the thyroid cartilage to move the larynx into view (BURP)

Pediatrics

Difficulty Viewing the Cords? BURP

Image from: Carrillo-Esper et al. Rev Mex Anes. 2008

Pediatrics

PREPARING FOR INTUBATION

Pediatrics

Indications for Intubation

•Primary respiratory disorder

• Severe hypoxemia (pneumonia, ARDS)

• Severe hypoventilation (bronchiolitis, emphysema, CLD)

•Primary neuromuscular disorder

• Myopathy (DMD, SMA)

• Altered mental status with hypoventilation (TBI, intoxication)

• Lack of airway protection (TBI, severe HIE, intoxication)

• Need for sedation with risk of airway protection or ventilation

•Tight control of paCO2 or pH

• Severe increased ICP (paCO2)

• Severe pulmonary hypertension (pH)

•To reduce metabolic demands in severe shock

Pediatrics

Use SOAP to Prepare for Intubation

•Suction

•Rigid catheter with constant suction (Yankauer)

•Oxygen

•10-15 LPM 100% (make sure it is not on a blender)

•Airway

•Appropriate sized tubes (estimated size and ½ size smaller)

•Appropriate sized laryngoscope blades

•Oral airways

•Pharmacology

•Based on diseasewww.mountainside-medical.com/products/Yankauer-Suction-Tip-Handle.html

Pediatrics

Medications for Intubation

•Premedication for laryngoscopy

•Sedation +/- analgesia

•Neuromuscular blockade•Make sure you can ventilate prior to neuromuscular blockade

•Make sure you can ventilate prior to neuromuscular blockade

•Make sure you can ventilate prior to neuromuscular blockade

Pediatrics

Premedication

•Atropine (neonates, infants)•0.02 mg/kg IV (0.1 – 1 mg total dose)

•Blunts the vagal response from laryngoscopy

•Use if bradycardic/risk of bradycardia

•Lidocaine (TBI, elevated ICP)•1 mg/kg IV

•Anesthetizes airway to blunt the ICP spike from laryngoscopy

Pediatrics

Sedation•Midazolam (85% of routine patients)

• 0.1 – 0.2 mg/kg IV

•Fentanyl (85% of routine patients)

• 2 – 6 mcg/kg IV (slow infusion, may cause rigid chest)

• Give sedative with fentanyl (no sedative effect)

•Propofol

• 1 mg/kg IV (may cause hypotension)

•Ketamine (shock states, asthma)

• 1 – 3 mg/kg IV (may cause increased bronchorrhea)

• 2 mg/kg IV for RSI

•Thiopental vs. Etomidate (elevated ICP)

• Thiopental 3 – 5 mg/kg IV (high risk of hypotension)

• Etomidate 0.2 – 0.6 mg/kg IV (may cause adrenal suppression)

Pediatrics

Neuromuscular Blockade

•Rocuronium vs. Vecuronium (85% of patients)

• Rocuronium 0.6 – 1.2 mg/kg IV (1.5 – 2 mg/kg IV for RSI)

• Vecuronium 0.1 – 0.4 mg/kg IV

• Effect may be prolonged in renal/hepatic failure

•Cisatracurium

• 0.2 mg/kg IV

• Cleared by Hoffman degradation (good for renal/hepatic failure)

•Succinylcholine

• 1 – 2 mg/kg IV; 4 mg/kg IM

• Patient will fasciculate, consider a defasciculating dose of rocuronium/vecuronium (1/10 dose)

• Beware of hyperkalemia in patients with neuromuscular disorders, burns, crush injuries, renal failure

Pediatrics

ENDOTRACHEAL INTUBATION

Pediatrics

Laryngoscope and ETT Selection

•Match the patient! If the patient is smaller than stated age (or unknown age), ETT can be estimated by the patient’s 5th finger size

Age Blade Size & Type ETT Size (mm; Uncuffed & Cuffed)

NB < 2 kg 0 Miller 2.5

NB > 2 kg ~ 6 mo 1 Miller 3.5 or 3.0 C

6 mo ~ 1 yr 1 ~ 1.5 Miller 4.0 or 3.5 C

1 yr ~ 2 yr 1.5 Miller 4.5 or 4.0 C

2 yr ~ 8 yr 2 Miller For UNcuffed tubes:

8 yr ~ 12 yr 2 Miller or 2 Macintosh

> 12 yr 3 Miller or 3 MacintoshSubtract 0.5 mm for Cuffed tubes

Pediatrics

Choose Your Blades

Miller Blades Macintosh Blades

Pediatrics

http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259

Head Tilt-Chin Lift Maneuver

Pediatrics

Alignment of The Airway:Children <3 years

McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84

O: Oral axisP: Pharyngeal axisL: Laryngeal axis

Large occiput flexes head and neck Shoulder roll will

help line up the pharyngeal and laryngeal axes

Extension of atlantooccipital joint will line up oral axis with the other two

Pediatrics

Placement of the Laryngoscope Blade (< 3 years)


Shoulder Roll for Infants

Pediatrics

Alignment of The Airway:Children >3 years

McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84

O: Oral axisP: Pharyngeal axisL: Laryngeal axis

Cushion under head will flex neck to line up pharyngeal and laryngeal axes

Extension of atlantooccipital joint will line up oral axis with the other two

Pediatrics

Placement of the Laryngoscope Blade (> 3 years)


Pediatrics

Laryngoscopic View

From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right)

http://www.bartleby.com/107/236.html%23i956

Pediatrics

ETT Insertion Depth – How Far?

•3 x ETT size

•Black marking or cuff past vocal cords

Pediatrics

POST-INTUBATION CARE

Pediatrics

How Do You Confirm Intubation?

•Bilateral & equal breath sounds

• If decreased on one side?

• If absent on one side and hypertympanic

•Improvement of oxygenation

• If saturations rapidly decrease?

•EtCO2 confirmation

•Colorimetric: Yellow = Yes

•Waveform analysis/quantitative: > 15 mm Hg

•CXR confirmation

•Absent sounds over stomach

•Mist in ETT during bag-ventilation

Pediatrics

Potential Complications of Oral Intubation

• Inability to ventilate (difficulty intubating and cannot BMV)

• This can lead to death

• Make sure you can ventilate prior to neuromuscular blockade

•Tube malposition (esophageal intubation)

• What will you notice/see?

•Airway trauma

• Teeth (check for loose or missing teeth before and after)

• Vocal cord injury (ineffective paralytic/VC closed during insertion)

• Subglottic edema/stenosis (incorrect tube size)

•Pulmonary disease

• Mainstem (left or right) intubation

• Pneumothorax (usually from over-exuberant bagging)

Pediatrics

Pneumothorax

From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)

http://www.ambu.com/

Pediatrics

Dental Trauma (DON’T DO THIS)

From: Windsor and Lockie. Anaesth and Int Care Med. 2008

Pediatrics

Endotracheal Intubation Objectives

•By the end of this workshop, the learner will be able to:

•Recite at least 3 indications and 5 complications associated with orotracheal intubation

•Derive the appropriate ETT size for orotracheal intubation using a formula and/or the patient’s age/weight/size

•Determine the appropriate sized laryngoscopy blade according to the patient’s age/weight/size

•Name at least 3 anatomic differences between the pediatric and adult airway

Pediatrics

QUESTIONS?

2013 Pediatric Fellows Boot Camp_ETI

Health & Medicine

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