App ped aw course1

Pediatrics

Pediatric Airway Management for the Advanced Practice

Provider

xxx00.#####.ppt 04/12/23 09:31 AMPediatrics Pediatrics

•Pediatric airway anatomy/physiology

•Points of emphasis/Discussion‐Airway adjuncts

‐BVM ventilation

‐Orortracheal intubation

•Skill stations

•Case-based performance

Course Outline

Pediatrics

The Pediatric AirwayAnatomy & Physiology


Objectives

By the end of this workshop, the learner will:‐List 5 anatomical differences between a pediatric and adult airway

‐Describe in your own words at least 3 physiologic factors that make pediatric patients more susceptible to hypoxemia

‐Discuss initial airway maneuvers using case-based examples


•Major differences between pediatric and adult airway are:

‐Size

‐Shape

‐Position

•Pediatric airway similar to adult at approx. 8-14 years of age

Children are NOT small adults!!!


Pediatric vs. Adult Airway



•Conical larynx

•Narrowest point @ cricoid ring

•Larger occiput

•Compliant and distensible large airways



•Larger adenoidal tissues

•Narrower tracheal diameter and shorter tracheal length

•Narrower larger airways


Physiologic Differences

•Lower %age of slow twitch muscle fibers

•Preferentially nose-breathers

•Compliant chest wall

•Ribs in a horizontal position

•Flatter diaphragm

•Higher oxygen consumption

•Higher MV:FRC


•10 mos. old with mild-to-moderate laryngotracheitis (i.e. viral croup). Child is sitting on mother’s lap and found to have intermittent stridor at rest, normal mentation, no agitation, mild retractions, some decreased air entry B/L and no cyanosis (SpO2 98% on RA).

‐Suction as needed

‐Oxygen as needed

‐Allow to assume position of comfort

Initial Maneuvers to Clear Airway


•3 year old with a retropharyngeal abscess exhibits dysphagia, odynophagia and some drooling. Also noticed is dysphonia, stertor, mild subcostal retractions. Child has normal mentation, no agitation, and no cyanosis (SpO2 95% on RA).


‐Oxygen as needed

‐Allow to assume position of comfort


xxx00.#####.ppt 04/12/23 09:31 AMPediatrics


•14 year old with meningitis who has a gradual change in mental status (from GCS of 13 to 9) over the course of the day. Exam reveals stertor, mild-moderate supra-sternal retractions during inspiration and no cyanosis (SpO2 93% on RA).


‐Oxygen as needed

‐Jaw thrust

‐Head tilt-chin lift

Pediatrics

Pediatric Airway ManagementAirway Adjuncts and Bag-Valve- Mask Ventilation


•Ensure airway patency‐Positioning

‐Repositioning

‐Suctioning

‐Head/shoulder roll

•Be careful in sizing

•Insertion technique‐3rd option

Points of Emphasis: Airway Adjuncts


•True life saving technique

•Utilize airway adjuncts

•Utilize two-person technique

•“Effective” = Chest Rise

•Excessive bagging due to user exuberance

‐Gastric distension

‐Barotrauma

Points of Emphasis: BVM Ventilation


Points of Emphasis: BVM Ventilation

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


•Perform the placement of airway adjuncts and effective BVM ventilation, at least twice, using an airway task trainer while:

‐Being instructed by your partner

‐Describing each step in the process

•Explain how to determine the appropriate sized airway adjuncts and BVM facemask according to anatomical landmarks

•Assemble the AmbuBagTM from its component parts

Skill Station Objectives

Pediatrics

Pediatric Airway ManagementOrotracheal Intubation


1st Commandment


3 Basic Components

•Most difficult airways can be recognized by 3 maneuvers:‐Examination of the oropharynx

‐Evaluation of the range of motion at the atlanto-occipital joint

‐Measurement of the mandibular displacement area


Examination of the oropharynx

•With mouth open to the fullest extent and tongue maximally protruding you can assess:

‐ROM at TMJ

‐Size of tongue

‐Palate


Examination of the oropharynx

•Mallampati Classification: degree of airway difficulty based on ability to visualize ‐Soft palate

‐Faucial pillars

‐Uvula


Range of motion at the AO joint

•Reduced ROM does not allow alignment of airway axes


Mandibular Displacement Area

•Tongue & soft tissues must be displaced and compressed into this space

•Adequate when distance between the anterior ramus of the mandible and the hyoid bone is:

‐3 cm (2 finger breadths) in a child

‐1.5 cm in an infant


•Identify the potential for a difficult airway

•Check ALL of your equipment!!

•Pre-oxygenate

•Positioning

•Duration of suctioning (< 10 sec)

Points of Emphasis: Oral Intubation


Difficulty Viewing the Cords? BURP

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

• BURP vs. Sellick Maneuver (i.e. cricoid pressure)



•Blade/ETT choice‐MacIntosh vs. Miller

‐Cuffed vs. Uncuffed

•LIFT DON’T ROCK!!!


•Confirmation‐CO2 Detector

•Post-Intubation Care‐PressureEasyTM

•Complications



•Carry out the proper sequence of steps involved in orotracheal intubation, at least twice, using an airway task trainer while:

‐Being instructed by your partner

‐Describing each step in the process

•Explain how to determine 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

Skill Station Objectives


•Assess and discuss the need for Rapid Sequence Intubation (RSI) given case-based examples

•Decide and discuss on an appropriate combination of medications required for special intubating situations given case-based examples

Objectives


Vignette 1

3 mos. old previously healthy infant presents with bronchiolitis and requires intubation for impending respiratory failure. Last fed breast milk 5 hrs ago.

‐What medications are you going to administer?

‐Why?

‐Requires RSI??


Premedicate (typical)

•Atropine (0.02 mg/kg IV)

•Midazolam (0.1-0.2 mg/kg IV/IM/IN)

•Fentanyl (2-4 mcg/kg IV)

•Rocuronium (1.2-1.5 mg/kg IV)


Vignette 2

8 year old with ALL who presents with septic shock and respiratory failure. HR = 150 and BP 80/35. Drank a coke 3 hrs ago.


‐Why?

‐What medications would you NOT give?

‐Requires RSI??


Premedication (alternative/sepsis)

•+/- Atropine (0.02 mg/kg IV)

•Ketamine (1-3 mg/kg IV)

•Rocuronium (1.2-1.5 mg/kg IV)


Vignette 3

18 year old previously healthy male presents S/P MVA. He acutely becomes altered with a GCS=7. His HR is 120 and BP is 120/80.


‐Why?

‐What medications would you NOT give?

‐Requires RSI??


Premedicate (risk of increased ICP)

•+/-Atropine (0.02 mg/kg IV)

•Lidocaine (1mg/kg IV)

•Thiopental (3-5 mg/kg IV) – if hemodynamically intact

OR

•Etomidate (0.25 mg/kg IV) – if hypotensive

App ped aw course1

Health & Medicine

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