Robin  Foster  MD  FAAP  FACEP  Division  Chief  Pediatric  Emergency  Medicine    Children’s  Hospital  of  Richmond  at  Virginia  

Commonwealth  University  Health  

How  hard  can  it  be?  �  260  Pediatric  Emergency  Airway  Encounters  by  Air  Transport  Personnel    �  Tollefsen  et  al  Dept  EM  Brigham  Harvard    PEC  Sept  2013  

�  4871  intubations  in  3  year  period  2007-­‐2009  �  260  were  pediatric  intubations  

 88  (33.8%)  medical    172  (66.2%)  trauma    #1  head  trauma  n=64    #2  seizures  n=26  

 

How  hard  can  it  be?  �  260  Pediatric  Intubations  

� Mean  age  7  years  �  98.8%  orotracheal  intubations  with  RSI  �   1st  attempt  78.6%  n=202  � Ultimate  rate  95.7%  n=246  �  </=  2  attempts  95.9%  n=236  � Medical  and  Surgical  diagnoses  had  equal  success  rates  �  All  age  groups  had  equal  success  rates  

�  0-­‐2  years    •8-­‐14  years  �  3-­‐7  years  

How  hard  can  it  be?  �  260  Pediatric  Intubations  

�  11  patients  not  successfully  intubated  �  7  LMA  placed  �  2  Combitube  �  2  Rescue  Cricothyrotomy  

�  Needle  Cricothyrotomy  in  a  2  yo  �  Surgical  Cricothyrotomy  in  a  14  yo  

�  No  mortality  because  of  a  failed  endotracheal  intubation  

�  3  patients  1.1%  were  managed  initially  and  successfully  with  EGD  

 Supraglo5c  Airways  � Any  airway  device  that  sits  outside  the  larynx  and  forms  a  seal  around  it  

� Original  device:  esophageal  obturator    airway  (EOA)  1973  

� Complications  included:  �  Incorrect  Placement  �  Esophageal  injury  � No  pediatric  sizes  

 

 Subglo5c  Airways  � Combitube  is  an  esophageal  tracheal  double  lumen  double  cuffed  airway  developed  in  the  early  1980s  

� Ventilation  is  traditionally  provided  thru  the  proximal  lumen  which  opens  at  the  larynx  while  inflating  the  distal  cuff  to  obstruct  the  esophagus    

� Two  sizes:  �  37  4-­‐5  foot  patient  �  41  >5  foot  patient  

� No  pediatric  sizes  

Pediatric  Supraglo5c  Airways  �  King  Airway  System  (LTS-­‐D  LT-­‐D  LT)  is  a  curved  tube  with  ventilation  apertures  located  between  two  balloons  with  one  valve  to  inflate  both  the  esophageal    and  the  oral  pharynx  balloon.  Introduced  US  2003  

�  Pediatric  sizes:  �  2.0  35-­‐45  inches  height  pt  �  2.5  41-­‐51  inches  height  pt  �  Average  2  yo  35  inches  

Pediatric  Supraglo5c  Airways  � King  airways  are  the  most  common  prehospital  supraglottic  airway  in  EMS    

� Cuff  volumes  �  2.0  25-­‐35  ml  �  2.5  35-­‐40ml  

� Pediatric  sizes  for  King  LT-­‐D  only:  no  gastric  outlet  

Pediatric  Supraglo5c  Airways  � The  patent  for  the  first  laryngeal  mask  airway  (LMA)  was  issued  to  a  British  anesthesiologist  Dr  Archie  Brain  in  1982    

�  Since  then  the  LMA  has  been  used  over  300  millions  times  in  anesthesia  and  emergency  airway  management  

� Comprised  of  an  airway  tube  and  an  elliptical  mask  with  an  inflatable  or  self  sealing  cuff  

� Term  LMA  has  been  replaced  by  the  term  SGA  because  of  number  of  new  devices  

Pediatric  Supraglo5c  Airways  � An  update  on  newer  pediatric  supraglottic  airways  with  recommendations  �  Jagannatman  et  al  Ped  Anesth  April  2015  

� Old  SGAs  �  LMA  classic  1987  and  LMA  Unique  1997  �  LMA  Proseal  2000/  pediatric  sizes  2004  

� New  SGAs  �  Air  Q    i-­‐gel    �  LMA  Supreme  Ambu  aura-­‐i  

Pediatric  Supraglo5c  Airways  LMA  Classic-­‐1st  generation   LMA    Proseal-­‐2nd  generation  

Pediatric  Supraglo5c  Airways  Air-­‐Q-­‐2nd  generation   i-­‐gel-­‐2nd  generation  

Inser;on  of  LMA  type  SGA  

Pediatric  Supraglo5c  Airways  Device   Cost  $   Smallest  size   Generation  

Gastric  out  Ease  1st  attempt  

LMA  Classic   80-­‐200   1.0    <5kg  1.5  5-­‐10kg  2.0  10-­‐20kg  2.5  20-­‐30kg  

1st   91%  

LMA  Unique   7-­‐10   1.0  <5kg   1st   89%  

LMA  Proseal   100-­‐250   1.0  <5kg   2nd   94%  

Air-­‐Q   7-­‐10   0.5<4kg   1st  (or  2nd)   99%  

Ambu-­‐aura   5-­‐8   1.0  <5kg   1st    (or  2nd)   93%  

LMA  Supreme   10-­‐20   1.0  <5kg   2nd   97%  

i  gel   10-­‐20   1.0  <5kg   2nd   91%  

Pediatric  Supraglo5c  Airways  Device   Leak  pressure  

Cm  H2O  Conduit  for  intubation  

Concerns  

LMA  Classic   15-­‐23   Narrow/long   Gastric  insufflation(GI)  

LMA  Unique   15-­‐18   Narrow/long   Low  pressure    GI  

LMA  Proseal   22-­‐23   Narrow/long   Requires  exchange  for  TI  

Air  Q   19-­‐25   Wide/short  

Ambu-­‐aura   16-­‐22   Wide/short   1.0  and  1.5  φ  TI  cuffed  tubes  

LMA  Supreme   17-­‐20   Narrow/long   Requires  exchange  for  TI  

i  gel   20-­‐27   Wide/short   Dislodges  

Applica;ons  of  SGA  data  �  If  a  child  has  received  BMV  prior  to  placement  of  the  SGA  then  gastric  decompression  is  important  either  prior  to  placement  of  SGA  or  use  SGA  with  a  gastric  outlet  

�  If  patient  requires  ongoing  positive  pressure  ventilation  or  has  intrinsic  lung  disease  then  gastric  outlet  and  high  leak  pressures  relevant  to  ensure  adequate  ventilation/oxygenation  

�  If  patient  ultimately  requires  definitive  airway  placement  then  the  shorter  wider  tubes  facilitate  conduit  tracheal  intubation  without  using  exchange  catheters/guide  wires  

Intuba;on  of  the  Pediatric  Pa;ent  � New  indirect  laryngoscopes  that  do  not  rely  on  the  alignment  of  the  oral-­‐pharyngeal-­‐tracheal  axes  

� Potential  to  benefit  pediatric  patient  population  greatly  because  of  the  relatively  small  size  of  the  pediatric  airway  and  the  difficulty  in  obtaining  direct  visualization  of  the  airway  past  the  small  oral  opening  

� Commonly  used  current  products  that  have  pediatric  blades  within  the  last  ten  years  include:  �  Glidescope  �  CMAC    �  Truview  EVO2  PCD    

Glidescopes  �  AVL  reusable  

�  4  size  blades  GVL  2,3,4,5  �  Delay  in  high  level  disinfection  process  

�  AVL  disposable  �  Two  size  video  batons  

�  1-­‐2  neonates/small  children  �  3-­‐4  children  /adults  

�  6  size  blades  �  Immediately  available  again  to  be  used    

Glidescope  Video  Batons  and  Blades  are  weight  based  Video  baton   Blade  size   Weight  parameter  (kg)  

1-­‐2   0   <1.5  

1   1.5-­‐3.8  

2   1.8-­‐10  

2.5   10-­‐28  

3-­‐4   3   10-­‐adult  

4   40  and  up  

The  Literature  on  Glidescopes  �  Kim  et  al  2008  British  Journal  Anesth  compared  the  glidescope  with  direct  laryngoscopy  in  203  children  �  >50%  of  the  time  the  glidescope  provided  a  better  glottic  view  but  a  longer  time  to  intubation  

�  36  seconds  with  a  glidescope  �  23.8  seconds  with  direct  laryngoscopy  

�  Lee  et  al  2013  found  that  a  Glidescope  blade  size  that  was  one  smaller  than  the  recommended  blade  based  on  weight  improved  the  view  of  the  glottis  compared  to  the  recommended  GL  blade  or  direct  laryngoscopy  �  Neutral  position  and  jaw  thrust  manuevers    instead  of  traditional  cricoid  pressure  improved  view  as  well  

The  Literature  on  Glidescopes  �   Validation  of  the  Glidescope  video  laryngoscope  in  the  pediatric  patient  Redel  et  al  Ped  Anesth  July  2009  �  60  patients  <  10  years  old  ASA  I-­‐III  airways  �  Randomized  by  airway  class  to  glidescope  vs  Macintosh  intubation    

�  Anesthesiologists  performed  the  intubations  � No  significant  difference  in  trauma  based  on  bleeding  in  the  airway  comparing  glidescope  to  Macintosh  

 

CMAC  � One  handle  size  � Reusable  Blade  sizes  

� Miller  0,1  � Mac  2,3,4  

� Disposable  Blades    � Miller  sizes  not  available  

The  Literature  on  CMAC  �  Studies  have  looked  at  infants  <10kg  (Mutlak  et  al  2014)  as  well  as  older  children  (Singh  et  al  2015)  in  terms  of  success  of  intubation  and  time  

�  Equal  success  comparing  CMAC  with  Macintosh  �  Better  visualization  of  the  glottis/cords  with  CMAC  �  Slightly  longer  times  to  intubate  using  indirect  versus  direct  larnygoscopy  28  sec  vs  26  sec  

�   Intubations  performed  by  anesthesiologists  who  had  experience  with  equipment  

�  Theory  is  that  this  difference  in  time  to  intubation  will  persist  because  of  the  parallax  of  placing  the  tube  thru  the  cords  based  on  an  indirect  image  that  requires  eye  hand  coordination  

TruView  EVO2  � Angled  blade  � Narrow  distal  portion  �  Integrated  oxygen  jet  cleaning  system  2-­‐5l/min  to  prevent  fogging  and  provide  apneic  oxygenation  

�  Infant  blade:  1-­‐10kg  

The  Literature  on  TruView  �  Infant  (Mutlak  et  al  2014)  and  children  (Singh  et  al  2015)  comparative  studies  demonstrate  the  best  visualization  of  the  cords  with  TruView  compared  to  direct  or  other  indirect  devices  

� Much  longer  time  to  intubate  52  sec  vs  28  sec  with  CMAC  and  26  sec  with  direct  laryngoscopy  

� No  difference  in  oxygenation  but  presumptively  because  of  the  ability  to  deliver  oxygen  during  the  process  

� TruView  had  much  lower  user  satisfaction  scores  

Cannot  intubate  Cannot  ven;late  neonate  or  infant  �  Surgical  cricothyrotomy  is  not  indicated  because  of  the  small  dimensions  of  the  cricothyroid  membrane  

� Cricoid  cartilage  is  an  important  circumferential  supportive  structure  for  the  trachea  to  maintain  patency  

�  Surgical  tracheostomy  is  the  ultimate  option  but  difficult  procedure    

� Needle  cricothyrotomy  or  needle  puncture  transtracheal  is  immediate  solution  

Needle  Cricothyrotomy  � Effective  ventilation  is  problematic  � High  pressure  gas  flow  is  required  to  overcome  the  small  diameter  resistance  

� No  data  on  using  transtracheal  jet  ventilation  on  infants  and  small  children  

� Animal  data  Wong  et  al  Peds  Anesthesia  2014  �  Jet  ventilator  or  a  commercial  oxygen  modulator    with  noncompliant  tubing  and  a  luerlock  connected  to  high  flow  oxygen  both  achieve  improved  oxygenation  over  the  same  time  frame  and  sustained  it  for  15  minutes  allowing  time  to  set  up  for  surgical  trach  

Nitric  oxide  in  Pediatric  Acute  Respiratory  Distress  Syndrome    � Bronicki  et  al  Multicenter  Randomized  Trial  Journal  of  Peds  Feb  2015  

� Hypothesis:  Inhaled  nitric  oxide  (iNO)  would  lead  to  improved  oxygenation  and  decreased  duration  of  mechanical  ventilation  in  pediatric  acute  RDS  

�  55  children  in  9  centers  randomized  to  iNO  or  placebo  

�  Survival  rate  between  the  two  groups  at  28  days  92%  22/24  in  iNO  and  72%  21/29  in  placebo  (p=0.07)  �  Significant  reduced  duration  of  mechanical  ventilation  �  Significant  increased  rate  of  ECMO  free  survival  

Pediatric  Airway  Cases:#1  �  2  yo  male  who  refuses  to  eat  and  is  febrile  to  102  

� Pt  is  anxious  and  scared  appearing  

� Mouth  open  

Epiglo5;s  � Etiologic  agents:  

�  Staph  aureus  �  Group  A  streptococcus  �  Candidal  supraglottitis  in  HIV  

� Pediatric  ENT  or  anesthesia    

� Ceftriaxone  and  clindamycin  

Pediatric  Airway  Cases:  #2    �  18  mo  old  female  with  runny  nose  for  two  days  and  now  with  audible  stridor  and  retractions  of  intercostals  with  nasal  flaring  at  rest  

Croup  �  Parainfluenza  virus  type  1  �  Xrays  rarely  needed  unless  child  excessively  febrile  or  toxic  appearing  

�  AP  view  with  steeple  or  pencil  sign  

�  Lateral  view  haziness  of  the  subglottic  region  and  distension  of  hypopharynx  more  sensitive  and  specific  

Pediatric  Airway  Cases:  #3  �  5  yo  male  who  has  fever  chills  malaise  and  decreased  po  

� Exam  with  left  sided  cervical  adenopathy  and  poor  visualization  of  the  posterior  pharynx  

Retropharyngeal  Abscess  �  Prevertebral  soft  tissue  swelling  >  the  width  of  the  vertebrae  

�  Try  to  take  film  in  retroflexed  position  instead  of  straight  upright  to  avoid  false  positives  

�  6mo-­‐6years  suppurative  changes  of  retropharyngeal  nodes  or  trauma  

�  Group  A  beta  hemolytic  strep,  nonhemolytic  strep,  Staph  aureus  or  bacteriodes  

�  CT/OR  drainage/clindamycin  and  zosyn  or  unasyn  

Pediatric  Airway  Cases:#4  �  18  mo  old  female  who  presents  with  cough,  high  fever  and  inspiratory  stridor  

� Case  #2  sent  home  two  nights  ago  with  diagnosis  of  croup  after  improving  s/p  decadron  and  epinephrine  

�  Inc  WOB  and  sats  90%  

Bacterial  Trachei;s  �  Persistent  subglottic  narrowing  

�  Post  croup  presents  much  like  epiglottitis  

� Mucosal  damage  and  impairment  of  local  immune  mechanisms  secondary  to  viral  infection  

�  Staph,  strep  pneum  or  pyogenes,  H  influenza  and  Moraxella  

Bacterial  Trachei;s  �  Intubation  with  anesthesia/pediatric  ENT  if  available  

� Ceftriaxone  and  Clindamycin  

Pediatric  Airway  Cases:  #5  �  2  yo  male  who  was  in  high  chair  and  acutely  developed  respiratory  distress  with  wheezing  and  marked  increased  work  of  breathing  and  hypoxia  sats  70s  

� Pt  has  a  history  of  asthma  but  no  response  to  bronchodilators  

Aspira;on  of  beef  macaroni  and  cheese  �  Expiratory  film  shows  hyperinflation  of  left  chest  because  of  left  main  stem  obstruction  

�  Intubate  right  main  stem  if  traditional  tube  placement  fails  and  oxygenate  and  ventilate  judiciously  secondary  to  risk  of  ptx  

�  IV  steroids  �  Rigid  bronchoscopy