En Pediatric Airway

7/23/2019 En Pediatric Airway

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Gawat Darurat Pediatric

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Pediatric Emergency

Copyright @, Ns.MOHAMMAD ALI HAMID



ASA as! "orce o# Ma#age$e#t o%

the Di%%icu&t Airway ' De%i#itio#s( difficult airway ) the c&i#ica& situatio# i# which a co#*e#tio#a&&y

trai#ed a#esthesio&ogist e+perie#ces di%%icu&ty with $as! *e#ti&atio#,di%%icu&ty with trachea& i#tuatio#, or oth.

difficult mask ventilation ) -/ i#ai&ity o% u#assisted

a#esthesio&ogist to $ai#tai# SpO0 1 234 usi#g 334 o+yge# a#dpositi*e pressure $as! *e#ti&atio# i# a patie#t whose SpO0 was234 e%ore a#esthetic i#ter*e#tio#5 or -0/ i#ai&ity o% the u#assisteda#esthesio&ogist to pre*e#t or re*erse sig#s o% i#ade6uate*e#ti&atio# duri#g positi*e pressure $as! *e#ti&atio#.

difficult laryngoscopy ) #ot ei#g a&e to see a#y part o% the vocal

cords with co#*e#tio#a& &ary#goscopy

difficult intubation ) proper i#sertio# with co#*e#tio#a&&ary#goscopy re6uires either -/ $ore tha# three atte$pts or -0/$ore tha# te# $i#utes



Pediatric PeriOperati*e Cardiac

Arrest -POCA/ 7egistry Co&&ects data %ro$ 89 &arge i#stitutio#s to

corre&ate perioperati*e pediatric deaths a#da#esthesia

he $a:ority are $edicatio# re&ated cardiacdeaths

22;'0339( 7espiratory e*e#ts i#creased %ro$03 perce#t to 0< perce#t.

he $ost co$$o# e*e#t &eadi#g to cardiac

arrest i# this category was &ary#gospas$,%o&&owed y airway ostructio#, i#ade6uateo+yge#atio#, i#ad*erte#t e+tuatio#, di%%icu&ti#tuatio# a#d ro#chospas$.



Pediatric Airway =$erge#cies

I#%re6ue#t&y e#cou#teredStridor History a#d Physica& =+a$i#atio#Mu&tip&e =tio&ogies

Co#ge#ita& I#%&a$$atory Iatroge#ic Neop&astic rau$atic



>rge#cy

Must assess the urge#cy o% the situatio#

"u&& a#d %ra#! discussio# o% the ris!s with

the pare#ts -a#d chi&d i% appropriate/

i#c&udi#g tracheosto$y a#d %ai&ure to

secure the airway



A#ato$y

I#%a#t &ary#+('More superior i# #ec!'=pig&ottis shorter, a#g&ed

$ore o*er g&ottis'?oca& cords s&a#ted( a#terior

co$$issure $ore i#%erior ' ?oca& process 34 o% &e#gth

'Lary#+ co#e'shaped(

#arrowest at sug&ottic cricoid

ri#g

'So%ter, $ore p&ia&e( $ay e

ge#t&y %&e+ed or rotateda#terior&y

I#%a#t to#gue is &arger Head is #atura&&y %&e+ed



History

Assess the urge#cy o% the situatio#

Si$u&ta#eous History a#d Physica& Cho!i#g Aggra*ati#g %actors

• "eedi#g, s&eepi#g, positio#i#g

hroat or #ec! pai# irth history

• Pre#ata&



Sig#s o% i$pe#di#g respiratory %ai&ure I#creased respiratory rate

Nasa& %&ari#g >se o% accessory $usc&es Cya#osis



Physica& =+a$i#atio#

Stridor Stertor

u&!y orophary#gea& #oise I#spiratory, e+piratory, or oth

Suprag&ottic I#spiratory

G&ottic I#spiratory progressi#g to iphasic

Sug&ottic I#spiratory progressi#g to iphasic

rachea& =+piratory



"&e+i&e Lary#goscopy(

Proper =6uip$e#t

Assess

#aresBchoa#ae

Assess ade#oid a#d

&i#gua& to#si&

Assess ?C $oi&ity

Assess &ary#gea&

structures



7adio&ogy(

P&ai# %i&$s( Chest a#d airway AP a#d

&atera&

=+piratory %i&$s



Airway "&ouroscopy

uic!, #o#i#*asi*e, a#d dy#a$ic study Suprag&ottic( 994 G&ottic( <4 Sug&ottic( ;34 rachea&( <94 ro#chia&( ;34

"ar superior to p&ai# %i&$sDisad*( radiatio# e+posure

3 rads -3.Gy/ per $i#ute



M7IBC

>sua&&y #ot use%u& i# a# acute setti#g

More re&ia&e %or e*a&uati#g #ec! $asses

a#d co#ge#ita& a#o$a&ies o% the &ower

airway a#d *ascu&ar syste$



reat$e#t Optio#s

He&io+

Ora& Airways

I#tuatio# =#dotrachea& Lary#gea& Mas!

racheosto$y=I procedure



He&io+

Graha$Es Law( %&ow rate

is i#*erse&y proportio#a&

to the s6uare root o% its

de#sity

He&iu$ <+ &ess de#se

tha# Nitroge#

Show# to e e%%ecti*e i#

upper airway ostructio#,

*ira& croup,poste+tuatio# stridor



He&io+

GosF et a&( I$$ediate positi*e respo#se i# <94 o%

patie#ts A*erage duratio# o% treat$e#t $i# to 9;

hours -o*era&& $ea# o% 02.hrs/ Lary#gotracheoro#chitis were $ore &i!e&y to

respo#d tha# other causes. -other causeswere upper airway ostructio#, poste+tuatio#

stridor, co#ge#ita& heart disease/



=#dotrachea& I#tuatio#

Mu&tice#ter study

8 out o% 0;; tota& =D i#tuatio#s 7apid Se6ue#ce I#tuatio# -;4/

ithout $edicatio#s -84/ Sedatio# without #euro$uscu&ar &oc!ade -84/

O*era&& success%u& i#tuatio#s 7SI 224 No# 7SI 2<4

O#&y out o% 8 re6uired surgica& i#ter*e#tio#



7apid Se6ue#ce I#tuatio#

7eco$$e#ded %or e*ery e$erge#cyi#tuatio# i#*o&*i#g a chi&d with i#tactupper airway re%&e+es y the Pediatric

=$erge#cy Medici#e Co$$ittee o% the A$erica# Co&&ege o% =$erge#cyPhysicia#s

Si$u&ta#eous ad$i#istratio# o% a#euro$uscu&ar &oc!ade age#t a#d asedati*e



I#tuatio#

7u&e o% Es( AgeB ) = siFe

Mucosa& i#:ury at 0c$ o% pressure. here%ore,a&ways chec! %or &ea!.

Spo#ta#eous *e#ti&atio#( a&&ows %or a &i$ited e+a$i#atio# o% the dy#a$ics o%*oca& cord $otio#.

Ap#eic tech#i6ue(

ur# to "iO0 334 prior to e+tuatio#. 8L O0B$i# %&ow *ia &ary#goscope Ge#era& ru&e to wor! ap#eic i# a proportio#a&

a$ou#t o% ti$e as reo+yge#atio#.



Lary#gea& Mas! Airway



racheoto$y

Cricothyroidoto$y is

di%%icu&t Bc o% s$a&&

$e$ra#e a#d %&e+ii&ity

=ar&y co$p&icatio#s P#eu$othora+, &eedi#g,

deca##u&atio#, ostructio#,

i#%ectio#s

Late co$p&icatio#s

Gra#u&o$a, deca##u&atio#,SGS, tracheocuta#eous

%istu&a



=I Procedure

-e+ utero i#trapartu$ treat$e#t/ Pre#ata& diag#osis is

crucia& "&atte#ed diaphrag$s,

po&yhydra$#ios

he head, #ec!,thora+, a#d o#e ar$are de&i*ered.

>terop&ace#ta&circu&atio# ca# e$ai#tai#ed %or '83$i#utes



Speci%ic =tio&ogies o% Airway

=$erge#ciesCo#ge#ita& Nec! Masses

Co#ge#ita& a#o$a&ies

Sy#dro$ic patie#ts I#%&a$$atory

"oreig# odies



Co#ge#ita& Nec! Masses

Der$oid cysts Mesoder$Bectoder$

eratoid cysts a#d

terato$as A&& 9 &ayers 034 i#cide#ce o%

$ater#a&

po&yhydra$#ios



Co#ge#ita& Nec! Masses

Ly$pha#gio$as

Capi&&ary, ca*er#ous,

cystic types

More airwayostructi*e whe#

%ou#d i# the a#terior

tria#g&e



CHAOS-co#ge#ita& high airway ostructio# sy#dro$e/

=$erge#t airway $a#age$e#t at the ti$e o%de&i*ery is !ey %or sur*i*a&

Pre#ata&&y

"&atte#ed diaphrag$s, po&yhydra$#ios, cer*ica& $ass =AM Me$ers

Mater#a&'%eta& specia&ist Neo#ata&ogist

A#esthesio&ogist Oto&ary#go&ogist Patie#t



Lary#gotracheoro#chitis

-Croup/ Parai#%&ue#Fa type

Ge#era&iFed $ucosa&

ede$a o% the &ary#+,

trachea, ro#chi



Lary#gotracheoro#chitis

reat$e#tHu$idi%icatio#

No scie#ti%ic data to support May worse# the situatio#

7ace$ic =pi#ephri#e 7educes $ucosa& ede$aBro#chia& re&a+atio#

Steroids Syste$ic *s. I#ha&ed

I#tuatio#



acteria& racheitis

Co$p&icatio# o% *ira&&ary#gotracheoro#ch

itis

"e*er, white cou#t,

respiratory distress%o&&owi#g a

co$p&icated course o%

croup

Staphy&ococcus

aureus

=#doscopy a#d

I#tuatio#



Acute Suprag&ottitis

Mi&d >7I thatprogresses o*er a %ewhours to se*ere throatpai#, droo&i#g, a#d%e*er

H. i#%&ue#Fa,parai#%&ue#Fa

reat$e#t I#tuatio# =$piric A+



Co#ge#ita& Sy#dro$es

C&ose e$ryo&ogica& de*e&op$e#t o% the

airways a#d the cra#io%acia& structures

=ar&y co$p&icatio#s are usua&&y $ore

pro%ou#d

Late co$p&icatio#s $ay e $ore sut&e



Co#ge#ita& Sy#dro$es a#d Airway

=$erge#ciesSy#dro$es o% %acia& a#o$a&ies

Pierre 7oi# Se6ue#ce reacher Co&&i#s Go&de#harBHe$i%acia& $icroso$ia

De%or$ities o% s!u&& shape CrouFo#EsBApertEs P%ie%%er



Pierre 7oi# Se6ue#ce

Microg#athia, re&ati*e$acrog&ossia with orwithout c&e%t pa&ate

I#tuatio# *ia the&atera& to#gueapproach

racheoto$y

G&ossope+y Superiostea& re&ease

o% $a#di&e



reacher Co&&i#s

Hypop&astic chee!s,Fygo$atic arches, a#d$a#di&e5

Microtia with possi&eheari#g &oss5

High arched or c&e%t pa&ate5 Macrosto$ia -a#or$a&&y

&arge $outh/5 Co&oo$as5 I#creased a#terior %acia&

height5

Ma&occ&usio# -a#terior ope#ite/5 S$a&& ora& ca*ity a#d airway

with a #or$a&'siFed to#gue5



Go&de#har J

He$i%acia& Microso$ia Ocu&oauricu&ar dysp&asia

Li$ited at&a#to'occipita& e+te#sio#



K&ippe&'"ei&

Co#ge#tia& %usio# o%

a#y 0 o% the < cer*ica&

*erterae

Short, i$$oi&e #ec!



CrouFo#EsB ApertEs

A#or$a& c&osure o% thecra#ia& sutures

Nasa& ca*ityNasophayr#gea&ste#osis' &eads to OSA

Associated a#o$a&ies SGS rachea& s&ee*es

reat$e#t Nasa& deco#gesta#tsB

ste#ts Se&ecti*e

ade#oidBto#si&&ecto$y racheosto$y Mid%ace ad*a#ce$e#t



Mucopo&ysaccharidoses

Hu#terEs, Hur&erEs,

Marateau+'La$y

Progressi*e i#%i&tratio#

o% MPS withi# theairway structures

reat$e#t racheosto$y Death y age 3'



Dow#Es Sy#dro$e

Mid%ace hypop&asia, $acrog&ossia, #arrow#asophary#+, a#d shorte#ed pa&ate.

I$$ature i$$u#e syste$

e#de#cy towards oesity G=7D is *ery pro$i#e#t =6ua&s a *ery di%%icu&t patie#t to sedate a#d sti&&

$ai#tai# a# airway

Lo#ger &i%espa# o% these patie#ts &eads to a#i#crease i# the i#cide#ce o% CH" a#d pu&$o#aryhyperte#sio# seco#dary to OSA



Dow#Es Sy#dro$e

Mitche&& et a&. 09 Dow#s Patie#ts

;4 OSA 94 Lary#go$a&acia

Syste$ic co$oridities 84 G=7D

Cause o% >pper airway ostructio# is age re&ated 0yrs o&d( &ary#go$a&acia is $ost co$$o# cause

• Age depe#de#t progressio# to OSA 10yrs o&d( OSA is $ost co$$o# cause

• De&ay i# diag#osis is co$$o# ecause sy$pto$s o*er&ap



Dow#Es Sy#dro$e

acos et a&. o% < patie#ts u#derwe#t upper airway surgery -a&& had DLB at

the sa$e ti$e/ JA with pi&&ar p&icatio#, >PPP

O*era&&(

<84 had sig#i%ica#t or co$p&ete re&ie% 04 had $oderate or se*ere residua& sy$pto$s "ai&ures(

Greater #u$er o% ostructi*e sites• Lary#gotrachea& ste#osis -094 o% %ai&ures/• o#gue ase

More se*ere >AO 7eco$$e#datio#s(

Co$prehe#si*e preoperati*e airway e*a&uatio# ai&or the surgica& procedure %or the site o% ostructio# C&ose %o&&ow up %or %ai&ures



Choa#a& Atresia

"ai&ure o% the rea!dow#

o% the uccophary#ge&

$e$ra#e

McGo*er# Nipp&e a#d

#asogastric %eedi#g CHA7G= associatio#

Co&oo$as Heart a#or$a&ities

7e#a& a#o$a&ies Ge#ita& a#or$a&ities =ar a#or$a&ities



"oreig# odies

0'year o&ds

Acute episode o% cho!i#gBgaggi#g

riad o% acute wheeFe, cough a#d

u#i&atera& di$i#ished sou#ds o#&y i# 34

'34 o% patie#ts $a#i%est #o o*ious

sig#s



"oreig# odies

Se*erity is deter$i#ed y

co$p&ete *s partia&

ostructio#

Pea#uts are $ost

co$$o# 7ight $ai#ste$

Larger dia$eter More air%&ow tha# &e%t

Narrow a#g&e o% di*erge#ce Cari#a sits o# the &e%t side



"oreig# odies



"oreig# odies

P&ai# radiography( 04 o% ro#chia& &esio#s a#d 134 o%

trachea& &esio#s do #ot show up

Airway "&ouroscopy( Ao*e the cari#a( 90'34 e&ow the cari#a( ;3'234

DLB( Go&d Sta#dard



Airway "oreig# odies



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En Pediatric Airway

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