Airway Management in Airway Management in TransportTransport

Toni Petrillo-Albarano, MDPediatric Critical Care MedicineChildren’s Healthcare of Atlanta at Egleston Children’s Hospital

ObjectivesObjectives

Overview of the differences Overview of the differences between the pediatric and adult between the pediatric and adult airwayairway

Intubation of the pediatric patientIntubation of the pediatric patient

Anatomic Considerations Anatomic Considerations in Pediatricsin Pediatrics

Relatively Large Occiput Large Tongue Larynx is anterior and superior Epiglottis may be floppy with acute

angle Narrowest portion is cricoid cartilage

The BasicsThe Basics

The airway in any patient can be: Physiologic

• maintained easily or with effort by the patient

Maintainable• with some assistance/positioning

Invasive Intervention• oral airway, nasal trumpet, or intubation

The BasicsThe Basics

To assist patient’s in maintaining an airway:

Clear mouth Position head Consider Airway adjuncts

Proper PositioningProper Positioning

A jaw thrust or head tilt maneuver will position the tongue so that it will not obstruct the airway

Remember that a child has a relatively large tongue compared to an adult

In infants it is possible to hyperextend the neck too much and cause the soft tissue to obstruct the airway

Nasal TrumpetNasal Trumpet

A nasal trumpet can be a useful adjunct

possible for the trumpet to be too long or too short

Oral AirwayOral Airway

An appropriately placed oral airway will pull the tongue forward and provide an unobstructed airway

If the oral airway is too long, it will stimulate a gag. If it’s too short, it will not lift the tongue.

Airway AdjunctsAirway Adjuncts

The use of airway adjuncts, such as the nasal trumpet and oral airway, will only provide an adequate airway.

The patient must have reasonable respiratory effort.

If the patient is unable to maintain adequate ventilation, he/she should be bagged or proceed to endotracheal intubation.

Indications for IntubationIndications for Intubation

1. 1. Unable to protect airway2. Inadequate ventilation3. Hypoxemic respiratory failure

requiring positive pressure4. Therapeutic (e.g.

Hyperventilation in head injury)

Difficult Airway Difficult Airway ConsiderationsConsiderations

Short, muscular neck Receding mandible Protruding incisors Uvula not visualized Limited TMJ mobility Limited C-spine

mobility

What do you need?What do you need?

Monitors -- cardiac and pulse oximetrySuction -- Yankauer or catheterMachine -- ventilator or bag/maskAirway -- Endotracheal tubeIntravenous -- peripheral or central lineDrugs --

sedation/analgesia/paralysis/atropine

LaryngoscopesLaryngoscopes

Straight Curved Fiberoptic

Proper visualizationProper visualization

The laryngoscope should be used to lift “up and out”. Do not rock back on upper teeth.

Curved blade tip is placed in vallecula and will lift epiglottis away from airway.

Straight blade tip is used to hold the epiglottis from beneath.

Proper ETT SizeProper ETT Size

Newborn - 6 months 3.5

6 months - 1 year 4.0

> 1 year 4 + age 4

Intubation ProcedureIntubation Procedure

Prepare Equipment Position patient

• Table height• “Sniffing” position

Pre-oxygenate• 4 max breath in 30

sec• 100% O2 for 3-5 min

Induction agent• sedative/analgesic

Neuromuscular blocker

Intubation• Laryngoscope in L hand• Insert on R of mouth and

sweep tongue to L• Advance in midline until

epiglottis visualized• Advance tip of blade

– into vallecula (curved blade)

– beneath epiglottis (straight blade)

• Lift towards feet– “up and out”, “Never

Lever”

Rapid Sequence IntubationRapid Sequence Intubation

Done when immediate airway stabilization is required or the patient has a “full stomach” • has eaten -- pregnancy• trauma -- abdominal mass• GER -- misc• bowel obstruction

Expedited with rapid acting drugs and avoidance of bag mask ventilation

Rapid Sequence IntubationRapid Sequence Intubation

Procedure• Pre-oxygenate• Rapid Induction Agents• Rapid Acting Neuromuscular Blocker• Sellick’s Maneuver• Intubate• Check breath sounds, inflate cuff (if

applicable)• Release cricoid pressure

Sellicks’ ManeuverSellicks’ Maneuver

Cricoid Pressure Closes esophagus against the

vertebral column protects against passive

regurgitation DO NOT release until airway is

secure !

Intubation MedicationsIntubation Medications

Goals: Provide adequate intubation

conditions• airway easily visualized• patient comfort (not fighting procedure)

Avoid complications• hemodynamic instability• ICP in head injury

AtropineAtropine

Blunts vagal response that can cause bradycardia and dries oral secretions

Dose = 0.02 mg/kg (min 0.1 mg) Adverse effects

• tachycardia• mydriasis• atropine flush• disorientation

BenzodiazepinesBenzodiazepines

Effective in providing anxiolysis and amnesia

Onset and duration vary between midazolam, lorazepam, and diazepam

Dose = 0.1 mg/kg Adverse Effects include: hypotension

and myocardial depression

FentanylFentanyl

Sedative/Analgesic Dose 2-5 mcg/kg Rapid Onset and short duration --

thus an excellent intubation med Virtually no CV side effects

KetamineKetamine

PCP Derivative, Dissociative Hypnotic Rapid Onset and short duration Dose = 1-2 mg/kg IV or 2-4 mg/kg IM Increases HR, and BP and thus may

be ideal for the patient with shock. Increases cerebral metabolic rate and

ICP and thus not a good choice in head injury or seizure

Thiopental (Pentothal)Thiopental (Pentothal)

Dose = 2-5 mg/kg Max Effect in 60 seconds Sedative Hypnotic that decreases

cerebral metabolic rate and ICP Hypotension and Myocardial

Depression are possible adverse effects

EtomidateEtomidate

Ultra short-acting non-barbiturate Ultra short-acting non-barbiturate hypnotic hypnotic

rapid induction of anesthesia with rapid induction of anesthesia with minimal cardiovascular effectsminimal cardiovascular effects

0.2-0.6 mg/kg over 30-60 seconds 0.2-0.6 mg/kg over 30-60 seconds Peak effect: 1 minute Peak effect: 1 minute Duration of action: 3-5 minutesDuration of action: 3-5 minutes Can cause adrenal suppressionCan cause adrenal suppression

Neuromuscular BlockersNeuromuscular Blockers

Recommend only rapid acting agents:• Succinylcholine - dose = 1 mg/kg IV• Rocuronium - dose = 0.6-1.2 mg/kg IV• Vecuronium - dose = 0.1-0.3 mg/kg IV• Mivacurium - dose = 0.2 mg/kg IV• Atracurium - dose = 0.2 mg/kg IV

Recommended Recommended Intubation “Cocktails”Intubation “Cocktails”

Controlled Intubation• Fentanyl & Lorazepam

or• Etomidate• Vecuronium/Rocuronium• + Atropine

Head Injury• Pentothal or Etomidate• Lidocaine 1 mg/kg IV• Vecuronium• Atropine

Septic Shock• Atropine• Ketamine• Rocuronium/

Vecuronium

Status Asthmaticus• Atropine• Ketamine• Lorazepam• Rocuronium/

Vecuronium

Physiologic Response Physiologic Response to Intubationto Intubation

Airway Airway ReflexesReflexes• LaryngospasmLaryngospasm• CoughCough• GagGag

Cardiovascular Cardiovascular ReflexesReflexes• Sinus bradycardiaSinus bradycardia• TachycardiaTachycardia• HypertensionHypertension• DysrhythmiasDysrhythmias

Assessing ETT placementAssessing ETT placement

Direct visualizationDirect visualization ETCOETCO22 (digital readout or color paper) (digital readout or color paper) Chest riseChest rise Auscultation (be certain to confirm Auscultation (be certain to confirm

absence of gastric breath sounds)absence of gastric breath sounds) ETT vapor (unreliable)ETT vapor (unreliable) Chest X-rayChest X-ray

Monitoring on TransportMonitoring on Transport

Physical ExamPhysical Exam EKG monitorEKG monitor Pulse oximeterPulse oximeter EETTCOCO22 Monitor Monitor

Reevaluate Reevaluate FrequentlyFrequently

CapnogramsCapnogramsNormalNormal

Zero baselineZero baseline Rapid, sharp up riseRapid, sharp up rise Alveolar plateauAlveolar plateau Well-defined end-tidal Well-defined end-tidal Rapid, sharp down strokeRapid, sharp down stroke

A—B DeadspaceB—C Dead space and alveolar gasC—D Mostly alveolar gasD End-tidal pointD—E Inhalation of CO2 free gas

CapnographyCapnographySudden loss of waveformSudden loss of waveform

Esophageal intubationEsophageal intubation Ventilator disconnectVentilator disconnect Ventilator malfunctionVentilator malfunction Obstructed / kinked ETTObstructed / kinked ETT

CapnographyCapnographyDecrease in waveformDecrease in waveform

Sudden Sudden hypotensionhypotension

Massive blood Massive blood lossloss

Cardiac arrestCardiac arrest

HypothermiaHypothermia PEPE CPBCPB

CapnographyCapnographyGradual increase in waveformGradual increase in waveform

Increased body tempIncreased body temp HypoventilationHypoventilation Partial airway obstructionPartial airway obstruction Exogenous COExogenous CO22 source source

(w/laparoscopy/CO(w/laparoscopy/CO22 inflation) inflation)

CapnographyCapnographySudden drop – not to zeroSudden drop – not to zero

Leak in systemLeak in system Partial disconnect of systemPartial disconnect of system Partial airway obstructionPartial airway obstruction ETT in hypopharynxETT in hypopharynx

CapnographyCapnographySustained low EtCOSustained low EtCO22

AsthmaAsthma PEPE PneumoniaPneumonia

HypovolemiaHypovolemia HyperventilationHyperventilation

40

30

Low ETCO2, but good plateau

CapnographyCapnographyCleft in alveolar plateauCleft in alveolar plateau

Partial recovery from Partial recovery from neuromuscular blockadeneuromuscular blockade

40

CapnographyCapnographyTransient rise in ETCOTransient rise in ETCO22

Injection of bicarbonateInjection of bicarbonate Release of limb tourniquetRelease of limb tourniquet

40

CapnographyCapnographySudden rise in baselineSudden rise in baseline

Contamination of the optical bench Contamination of the optical bench – need to recalibrate– need to recalibrate

40

QuestionsQuestions

1. Which drug is not used in the 1. Which drug is not used in the intubation of a head injury patient?intubation of a head injury patient?• A. KetamineA. Ketamine• B. ThiopentalB. Thiopental• C. LidocaineC. Lidocaine• D. EtomidateD. Etomidate

QuestionQuestion

2.Capnograph 2.Capnograph representsrepresents

A. Esophageal A. Esophageal intubationintubation

B. Ventilator B. Ventilator disconnectdisconnect

C. Obstructed / C. Obstructed / kinked ETTkinked ETT

D. All of the D. All of the aboveabove

QuestionQuestion

3. Appropriate ETT size for a 6 year 3. Appropriate ETT size for a 6 year old calculated by formula is?old calculated by formula is?• A. 6.0A. 6.0• B. 4.5B. 4.5• C. 5.0C. 5.0• D. 5.5D. 5.5

QuestionQuestion

4. True or False:4. True or False:• Curved blade tip is placed in vallecula

and will lift epiglottis away from airway

QuestionQuestion

5. All of the following are 5. All of the following are indications for intubation except:indications for intubation except:• A. A. Unable to protect airway• B. B. Inadequate ventilation• C. C. Hypoxemic respiratory failure

requiring positive pressure• D. GCS 10D. GCS 10