PAEDIATRIC AIRWAY
-
Upload
shailesh-kohad -
Category
Health & Medicine
-
view
216 -
download
3
Transcript of PAEDIATRIC AIRWAY
![Page 1: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/1.jpg)
DR. SHAILESH K. KOHAD
ANAESTHESIA SPECIALIST
KING SAUD MEDICAL CITY, RIYADH.
![Page 2: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/2.jpg)
ANATOMY
PHYSIOLOGY
AIRWAY ASSESSMENT
AIRWAY MANAGEMENT
DIFFICULT AIRWAY MANAGEMENT
UNANTICIPATED DIFFICULT AIRWAY
AIRWAY MANAGEMENT IN SPECIAL CASES
![Page 3: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/3.jpg)
![Page 4: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/4.jpg)
Relatively large
Anterior flexion may cause airway obstruction
![Page 5: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/5.jpg)
Obligate Nasal Breathers
Poor tolerance to obstruction
![Page 6: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/6.jpg)
Relatively Large
Obstructs Airway
Neck extension may not relieve obstruction
Difficult to visualize larynx
![Page 7: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/7.jpg)
Adult epiglottis broader, axis parallel to trachea
Infant epiglottis omega shaped and axis angled away from trachea
More difficult to lift an infant’s epiglottis with laryngoscope blade
Straight laryngoscope blade completely elevates the epiglottis, preferred for pediatric laryngoscopy
More susceptible to trauma
![Page 8: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/8.jpg)
Laryngeal apparatus develops from brachial clefts and descends caudally hence Infant’s larynx is higher in neck (C2-3) compared to adult’s (C4-5)
More Anterior
Intubation more difficult
![Page 9: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/9.jpg)
Infant’s vocal cords have more angled attachment to trachea, whereas adult vocal cords are more perpendicular
Difficulty in nasal intubations where “blindly” placed ETT may easily lodge in anterior commissure rather than in trachea
![Page 10: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/10.jpg)
Narrowest portion
↑ resistance with airway edema or infection
Acts as “cuff” during tracheal intubation
Tight fitting ETT may cause edema and trouble upon extubation
Uncuffed ETT preferred for children < 8 years old
Fully developed cricoidcartilage occurs at 10-12 years of age
![Page 11: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/11.jpg)
Funnel shaped
Small diameter (6mm), high compliance
↑ resistance with airway edema or infection
Collapses easily with neck hyperflexion or hyperextension
![Page 12: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/12.jpg)
Alveoli ↑ Closing Capacity & ↑ air trapping
Pulmonary Vessels ↑ Pulmonary vascular resistance
(PVR) Very sensitive to constriction by
hypoxia, acidosis and hypercarbia
Chest Wall Horizontal ribs ↑ A-P diameter ↑ compliance due to weak rib cage Breathing is all diaphragmatic FRC determined solely by elastic
recoil of lungs Chest wall collapses with negative
pressures
![Page 13: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/13.jpg)
Compared to Adults Larger occiput
Nasal Breathers
Larger tongue
Epiglottis is floppier
Larynx Anterior & Cephalad
Funnel shaped Trachea
Cricoid Cartilage Narrowest
![Page 14: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/14.jpg)
Type I & II pulmonary epithelial cells Pulmonary surfactant produced by Type II
pneumocytes at 24 wks GA Sufficient surfactant present after 35 wks GA Premature infants prone to respiratory
distress syndrome (RDS) because of insufficient surfactant
Betamethasone can be given to pregnant mothers at 24-35 wks GA to accelerate fetal surfactant production
![Page 15: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/15.jpg)
High metabolic rate (5-8 ml/kg/min) Oxygen consumption of infant (6 ml/kg/min) is twice that
of an adult (3 ml/kg/min) [Less Oxygen Reserve] Tidal volume is relatively fixed (6-7 ml/kg/min) Minute Alveolar Ventilation is more dependent on
increased Respiratory Rate than on Tidal Volume Ratio of Alveolar Minute Ventilation to FRC is doubled
under circumstances of hypoxia, apnea or anesthesia Lung compliance is less while chest wall compliance is
more than those in adults - Reduced FRC and Atelectasis. Infant’s FRC is diminished and de-saturation occurs more
precipitously Lack Type I muscle fibers, fatigue more easily Prone to Bradycardia - Laryngeal stimulation and hypoxia
![Page 16: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/16.jpg)
![Page 17: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/17.jpg)
Poiseuille’s law: R = 8nl/ πr4
![Page 18: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/18.jpg)
![Page 19: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/19.jpg)
Best to 1st look from afar
Is the chest moving?
Can you hear breath sounds?
Are there any abnormal airway sounds (e.g.. Stridor, snoring)?
Is there increased respiratory effort with retractions or respiratory effort with no airway or breath sounds?
![Page 20: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/20.jpg)
URTI - cough, laryngospasm, bronchospasm, desaturation during anesthesia
Snoring – Adenoid Hypertrophy, OSA, Upper Airway Obstruction Chronic Cough – Subglottic Stenosis, Previous Tracheoesohageal Fistula
Repair Productive Cough - Bronchitis, Pneumonia Sudden Onset of New Cough – Foreign Body Aspiration Inspiratory Stridor - Macroglossia, Laryngeal Web, Laryngomalacia,
Extrathoracic Foreign Body Hoarse Voice - Laryngitis, Vocal Cord Palsy, Papillomatosis Asthma - Bronchospasm Repeated Pneumonias - GERD, CF, Bronchiectasis, Tracheoesophageal
Fistula, Immune Suppression, Congenital Heart Disease Previous Anesthetic Problems Atopy, Allergy – Increased Airway Reactivity Congenital Syndrome - Pierre Robin Sequence, Treacher Collins, Klippel-
Feil, Down’s Syndrome, Choanal atresia Environmental Smokers
![Page 21: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/21.jpg)
Facial expression
Nasal flaring
Mouth breathing
Color of mucous membranes
Retractions (suprasternal, intercostal, subcostal)
Respiratory rate
Voice change
Mouth opening
Size of mouth
Mallampati
![Page 22: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/22.jpg)
Loose or missing teeth.
Size and configuration of palate.
Size and configuration of mandible (side view).
Presence of inspiratory stridor: Epiglottitis, croup, extrathoracic foreign body.
Both inspiratory and expiratory stridor: Aspirated foreign body, vascular ring, or large esophageal foreign body.
Prolonged expiration: lower airway disease?
Baseline oxygen saturation in room air.
![Page 23: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/23.jpg)
Laboratory and radiographic evaluation extremely helpful with pathologic airway
AP and lateral films and fluoroscopy may show site and cause of upper airway obstruction
MRI/CT more reliable for evaluating neck masses, congenital anomalies of the lower airway and vascular system
Perform radiograph exam only when there is no immediate threat to the child’s safety and in the presence of skilled personnel with appropriate equipment to manage the airway
Intubation must not be postponed to obtain radiographic diagnosis when the patient is severely compromised.
Blood gases are helpful in assessing the degree of physiologic compromise; however, performing an arterial puncture on a stressed child may aggravate the underlying airway obstruction
![Page 24: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/24.jpg)
Simple things to improve airway patency Suction nose and
oropharynx
Reposition child/ allow child to assume position of comfort
Head-tilt-chin lift/ jaw thrust
Use airway adjuncts- NPA/ OPA
Bag and Mask Ventilation
Intubation
![Page 25: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/25.jpg)
S: Suction Catheters (6 - 16 french) and Yankauer tips (two sizes)
O: Oxygen and how to deliver Nasal cannula, oxygen flow, masks and appropriate bag
A: Airway Appropriate ETT, oral/nasal airway, stylets, laryngoscopes
P: Pharmacology RSI meds
ME: Monitoring Equipment EtCO2 detector, stethescope, monitors
![Page 26: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/26.jpg)
Measure length - Pt’s earlobe to tip of nose
Duration < 10 sec.
May result in Hypoxia, ↓ HR (vagal), Bronchospasm, Larygospasm, Atelectasis
Appropriate suction catheter size
Neonates 5-6 Fr
Infants 6-8 Fr
Older kids 10 Fr
AgePressure
(mmHg)
< 1 yr 60-80
1-12 yrs 80-120
13-17 yrs 100-150
![Page 27: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/27.jpg)
Oral
![Page 28: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/28.jpg)
Nasal
![Page 29: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/29.jpg)
Correct size Incorrect size
![Page 30: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/30.jpg)
• Too small: will not adequately displace tongue• Too large: may obstruct larynx and/ or interfere with
mask fit
![Page 31: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/31.jpg)
Place OPA against side of face. With flange at the corner of the mouth the tip should reach angle of the jaw
![Page 32: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/32.jpg)
• Distance from nares to angle of mandible approximates the proper length• Nasopharyngeal airway available in 12F to 36F sizes• Shortened endotracheal tube may be used in infants or small children• Avoid placement in cases of hypertrophied adenoids - bleeding and
trauma
![Page 33: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/33.jpg)
•Clear, plastic mask with inflatable rim provides atraumatic seal
•Proper area for mask application-bridge of nose extend to chin
•Maintain airway pressures <20 cm H2O
•Place fingers on mandible to avoid compressing pharyngeal space•Hand on ventilating bag at all times to monitor effectiveness of spontaneous breaths•Continous postitive pressure when needed to maintain airway patency
![Page 34: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/34.jpg)
![Page 35: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/35.jpg)
3 sizes:
Age Volume (ml)
Infant 500
Child 1000
Adolescent 2000
![Page 36: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/36.jpg)
Goals of Larynoscopy
![Page 37: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/37.jpg)
The problem is…
…but we are here.
Cords are here…
![Page 38: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/38.jpg)
The aim is…
To “see around the corner”
• The goal of DL…
• To get rid of the corner
• To create straight line of
sight
![Page 39: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/39.jpg)
Oral axis
Pharyngeal axis
Tracheal axis
Oral
Pharyngeal
Tracheal
![Page 40: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/40.jpg)
![Page 41: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/41.jpg)
![Page 42: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/42.jpg)
Straight blades are placed under the epiglottis and used to lift anteriorly to expose the cords.
Curved blades are placed in the valecula and lifted anteriorly to expose the cords.
Macintosh
Miller
Wisconsin
![Page 43: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/43.jpg)
Miller blade is preferred for infants and younger children
Facilitates lifting of the epiglottis and exposing the glottic opening
Care must be taken to avoid using the blade as a fulcrum with pressure on the teeth and gums
Macintosh blades are generally used in older children
![Page 44: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/44.jpg)
Age Blade/Size
Infant Miller 1
2 years old Miller 2
12 years old Miller/Mac 3
“Switch to a 2 at 2”
![Page 45: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/45.jpg)
For neonates endotracheal tube size roughly corresponds to 1/10th of gestational age rounded down to the nearest size. For example
A 36 week premie would get a 3.5 ETT
A 28 week premie would get a 2.5 ETT
AgeETT Size (ID)
(mm)ETT Length
(cm)
> 6 months 3 – 3.5 10
6 months – 1 yr 3.5 – 4.0 11
1 yr – 2 yr 4.0 – 5.0 12
![Page 46: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/46.jpg)
SIZE
Uncuffed ET tube: (Age in years / 4) + 4
Uncuffed ET tube: (Age in years + 16) / 4
(rounded to nearest 0.5 mm)
Cuffed ET tube: (Age in years / 4) + 3
LENGTH
ET tube Depth (Lip): ET tube Size (ID) x 3
ET tube Depth (Lip): (Age in yrs / 2) + 12
![Page 47: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/47.jpg)
Uncuffed ETT recommended in children < 8 yrs old to avoid post-extubation stridor and subglottic stenosis
Cuffed ETT preferable in cases of: High risk of Aspiration (ie. Bowel obstruction) Low Lung Compliance (ie. ARDS, pneumoperitoneum, CO2
insufflation of the thorax, CABG) Precise control of Ventilation and pCO2 (ie. increased intracranial
pressure, single ventricle physiology)
Disadvantages of cuffed ETT: smaller size increases airway resistance, increase work of breathing, poorly designed for pediatric pts, need to keep cuff pressure < 25 cm H2O
Disadvantages of uncuffed ETT: more tube changes for long-term intubation, leak of anesthetic agent into environment, require more fresh gas flow > 2L/min, higher risk for aspiration
For “short” cases when ETT size > 4.0, choice of cuff vs uncuffedprobably does not matter
![Page 48: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/48.jpg)
![Page 49: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/49.jpg)
Remember DOPE
D Displaced ETTETT may be in trachea or in
right or left mainstem bronchus
OObstruction of
ETTSecretions, blood, pus,
foreign body, kinked ETT
P PneumothoraxSimple
Tension
EEquipment
failure
Disconnection of O2 source, leak in vent circuit, loss of power/ vent malfunction
![Page 50: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/50.jpg)
Use largest size that can pass easily down the ETT
Ideally not larger than half the diameter of ETT to avoid causing atelectasis
TIP: choose double the ETT
e.g. 4.0 i.d. ETT choose 8 Fr suction catheter
![Page 51: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/51.jpg)
Postintubation Croup Incidence 0.1-1%
Risk factors: large ETT, change in patient position introp, patient position other than supine, multiple attempts at intubation, traumatic intubation, pts ages 1-4, surgery >1hr, coughing on ETT, URI, h/o croup
Tx: humidified mist, nebulized racemic epinephrine, steroid
Laryngotracheal (Subglottic) Stenosis Occurs in 90% of prolonged endotracheal intubation
Lower incidence in preterm infants and neonates due to relative immaturity of cricoid cartilage
Pathogenesis: ischemic injury secondary to lateral wall pressure from ETT, edema, necrosis and ulceration of mucosa, infection
Granulation tissues form within 48hrs leads to scarring and stenosis
![Page 52: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/52.jpg)
• More anatomical fit • Sealing at low pressures• More distal position• Greater permeability for nitrous
oxide
• For neo ≤ 3 kg and infants ≤ 1 yr, ID = 3.0 mm
• For children 1 to 2 years of age, ID = 3.5 mm
• For children ≥ 2 years, ID = Age/4 + 3.5
• Post-intubation croup was 0.4% (2/500 children)
![Page 53: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/53.jpg)
Rigid LaryngoscopyThe retromolar, paraglossal, or lateral approach to rigid laryngoscopy utilizing a straight blade.
![Page 54: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/54.jpg)
LEMON Look
Short neck, large tongue, micrognathia
Evaluate 3-3-2 3 finger breadths of mouth
opening 3 finger breadths submental to
hyoid 2 finger breadths hyoid to thyroid
Mallampati Obstruction Neck mobility
![Page 55: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/55.jpg)
LMAs (laryngeal mask airway) I-LMAs (intubating LMA) Rigid bronchoscopy Flexible bronchoscopy Lighted stylet Bullardscope Fiberoptic intubation Surgical airway Combitube Bougie
Pick one or two and practice
![Page 56: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/56.jpg)
Helpful for infants & children with immobile or shortened necks.
Either by an assistant or the laryngoscopist.
![Page 57: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/57.jpg)
![Page 58: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/58.jpg)
Supraglottic airway device developed by Dr. Archie Brain
Useful in difficult airway situations
Conduit of Drug Administration (ie. Surfactant) Types of LMAs: Classic LMA, Flexible LMA, ProSeal LMA,
Intubating LMA Contraindications: Full Stomach, Gag reflex, FBs, Airway
obstruction, High ventilation pressure
Disadvantages: Laryngospasm, aspiration
LMA Size Weight Max. Cuff Vol. (ml)
ETT Size (IDmm)
1.0 ≤ 5 kgs 4 3.5
1.5 5 – 10 kgs 7 4.0
2.0 10 – 20 kgs 10 4.5
2.5 20 – 30 kgs 14 5.0
3.0 30 – 50 kgs 20 6.0
4.0 50 – 70 kgs 30 7.0
5.0 > 70 kgs 40 8.0
![Page 59: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/59.jpg)
![Page 60: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/60.jpg)
![Page 61: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/61.jpg)
INSERTION TECHNIQUE
![Page 62: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/62.jpg)
![Page 63: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/63.jpg)
![Page 64: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/64.jpg)
Only sizes 3, 4, 5
Same rules and sizing as LMA
Need special armored tube for intubation
Leave LMA portion in place in field
![Page 65: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/65.jpg)
Laryngeal Tube Latex-free, single-lumen silicone tube, which is closed at distal end
Two high volume-low pressure cuffs, a large proximal oropharyngeal cuff and a smaller distal esophageal cuff
Both cuffs inflated simultaneously via a single port
Situated along length of oropharynx with distal tip in esophagus
Sizes 0-5, neonates to large adults
![Page 66: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/66.jpg)
Cobra PerilaryngealAirway
Perilaryngeal airway device with distal end shaped like a cobra-head
Positioned into aryepiglotticfolds and directly seats on entrance to glottis
Inflation of the cuff occludes the nasopharynx pushing the tongue and soft tissues forward and preventing air leak
Available in sizes pediatric to adult ½ to 6
![Page 67: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/67.jpg)
Not useful in most kids
Easy to place
Two sizes Small (4 to 5.5 feet tall) Regular (over 5.5 feet tall)
Contraindications Gag reflex Esophageal disease Caustic ingestions FBs/Airway obstruction
![Page 68: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/68.jpg)
Two person technique
Replaces stylet
Able to use with poor view
Intubate over it
Outer diameter – 5 mm
Total length – 60 cm
Small upturned distal end bend at 38⁰ helps in passage
KIWI GRIP
![Page 69: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/69.jpg)
![Page 70: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/70.jpg)
![Page 71: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/71.jpg)
SHIKANI FIBREOPTIC SCOPE
![Page 72: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/72.jpg)
![Page 73: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/73.jpg)
![Page 74: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/74.jpg)
Can’t ventilate
Can’t intubate
LMA contraindication (massive orofacial trauma) or not working
All intervations FAILED
![Page 75: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/75.jpg)
![Page 76: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/76.jpg)
![Page 77: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/77.jpg)
< 5 years old Needle cricothyrotomy and bag ventilation
5 to 10 years old Needle cricothyrotomy and bag ventilation
If oxygen saturation is inadequate, Transtracheal jet ventilation
> 10 years Needle cricothyrotomy with TTJV
Surgical cricothyrotomy – Contraindicated in < 10 yrs
![Page 78: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/78.jpg)
3-5cc syringe: 1-2cc saline OR 12- or 14-gauge IV
![Page 79: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/79.jpg)
Identify CTM and stabilize/prep larynx Insert needle on syringe, direct inferiorly
Large bore needle (12-16 gauge) Catheter over needle
Advance catheter Connect to TTJV (BVM for infants - 3.0 ETT)
Oxygen pressure (20-30 psi) 1 second on/2-3 seconds off
Complications (Similar to other cricothyrotomy) Bleeding Pneumothorax, Subcutaneous Emphysema, Pneumo-mediastinum Barotrauma Esophageal, Laryngeal or Tracheal Injury Obstruction Infection Subglottic stenosis
![Page 80: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/80.jpg)
Beneficial for children who cannot be “ventilated” by other route
![Page 81: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/81.jpg)
Percutaneous needle cricothyrotomy provides only a mean for oxygen insufflationand does not reliably provide adequate ventilation.
![Page 82: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/82.jpg)
TTJV
![Page 83: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/83.jpg)
![Page 84: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/84.jpg)
Broselow-Luten Emergency System Color-coded bags with equipments
Quicker, more efficient
Most accurate 3.5 - 25 kg
![Page 85: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/85.jpg)
![Page 86: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/86.jpg)
![Page 87: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/87.jpg)
Congenital Neck Masses (Dermoid cysts, cystic teratomas, cystic hygroma,
lymphangiomas, neurofibroma, lymphoma, hemangioma)
Congenital Anomalies (Choanal atresia,tracheoesophageal fistula,
tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular ring, tracheal stenosis)
Congenital Syndromes (Pierre Robin Syndrome, Treacher Collin, Turner,
Down’s, Goldenhar , Apert, Achondroplasia, Hallermann-Streiff, Crouzan)
Inflammatory (Epiglottitis, acute tonsillitis, peritonsillar
abscess,retropharyngeal abscess, laryngotracheobronchitis,bacterialtracheitis,adenoidal hypertrophy,nasal congestion, juvenile rheumatoid arthritis)
Traumatic/Foreign Body (burn,laceration,lymphatic/venous obstruction,fractures/dislocation, inhalational injury, postintubationcroup (edema),swelling of uvula
Metabolic (Congenital hypothyroidism, mucopolysaccharidosis, Beckwith-
Wiedemann Syndrome,glycogen storage disease, hypocalcemia laryngospasm)
![Page 88: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/88.jpg)
CYSTIC TERATOMA
![Page 89: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/89.jpg)
Occurs in 1/ 3000-5000 births
Most common type is the blind esophageal pouch with a fistula between the trachea and the distal esophagus (87%)
Feeding difficulties (coughing, choking and cyanosis) and breathing problems
Associated with congenital heart (VSA, PDA, TOF), VATER, GI, musculoskeletal and urinary tract defects
![Page 90: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/90.jpg)
![Page 91: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/91.jpg)
Complete nasal obstruction of the newborn
Occurs in 0.82/10 000 births Unilateral nare (right>left) During inspiration, tongue
pulled to palate, obstructs oral airway
Bilateral choanal atresia is Airway Emergency
Death by asphyxia Associated with other
congenital defects
![Page 92: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/92.jpg)
Occurs in 1/8500 births
Autosomal recessive
Obstruction is usually at the nasopharyngeal level
![Page 93: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/93.jpg)
Mandibulofacial dysotosis
Occurs in 1/10 000 births
![Page 94: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/94.jpg)
Unilateral Absent Thumb
![Page 95: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/95.jpg)
Trisomy 21 Occurs in 1/660 births
![Page 96: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/96.jpg)
![Page 97: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/97.jpg)
Exomphalos MacroglossiaGigantism Syndrome
Overgrowth Syndrome
Occurs in 1/13000-15000 births
Short Arm of Chromosome 11p15
Autosomal dominant
![Page 98: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/98.jpg)
Haemophilus influenzae type B Occurs in children ages 2-6 years Disease of adults due to widespread H. influenza vaccine
![Page 99: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/99.jpg)
![Page 100: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/100.jpg)
THUMB SIGN
CHERRY RED EPIGLOTTIS
![Page 101: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/101.jpg)
Parainfluenza virus
Occurs in children ages 3 months to 3 years
Barking cough
Progresses slowly
Medically managed with oxygen and mist therapy, racemic epinephrine neb and IV dexamethasone (0.25-0.5mg/kg)
Indications for intubation: progressive intercostal retraction, obvious respiratory fatigue, and central cyanosis
![Page 102: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/102.jpg)
![Page 103: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/103.jpg)
CLEFT LIP AND PALATE Most common congenital
face malformation
APERT AND CROUZON Maxillary hypoplasia
Nasopharyngeal airway compromise
GOLDENHAR SYNDROME
Unilateral anomalies
Higher incidence of airway anomalies
![Page 104: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/104.jpg)
LARYNGOMALACIA
A sequence between fully formed to atresia
LARYNGEAL WEB
TRACHEAL ATRESIA
Survive only if tracheoesophagealfistula or emergent tracheostomy done
SUBGLOTTIC STENOSIS
![Page 105: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/105.jpg)
HEMANGIOMA OR LYMPHANGIOMA Only about 30% present at
birth
![Page 106: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/106.jpg)
RULES
“Use your common sense”
“ Do not continue to do the same thing and expect different results’’
“Easier comes first”
“Each difficult intubation is a different”
![Page 107: PAEDIATRIC AIRWAY](https://reader034.fdocuments.in/reader034/viewer/2022052223/55a715b01a28ab37358b4811/html5/thumbnails/107.jpg)