Ron Brown - Airway Management
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Transcript Ron Brown - Airway Management
Pediatric Airway
Management
SNOHOMISH COUNTY EMS
OBJECTIVES
Anatomy
Physiology
Equipment
Establish respiratory distress present
Technique
Post intubation management
Pitfalls and Pearls
Difficult airway
ANATOMY
Unique <2 years old
Approaches normal adult airway by 8 years old
Glottic opening high and anterior
C1, transitions to C3/4, then C5/6 by adulthood
More soft tissue, less tone
Consider copying fig 20-2
p 270 here
ANATOMY
Large tongue in relation to oral cavity
Large tonsils and adenoids that can bleed (no
blind nasotracheal intubations)
Angle of epiglottis to laryngeal opening more
acute
ANATOMY
Large occiput/cranium flexes the neck
Avoid further neck flexion
Use sniffing position
Neck flexed, head extended
ANATOMY
Small cricothyroid membrane
<3-4 years old almost nonexistant
>8 similar to adults
No surgical cricothyroidotomy <8
Cricoid ring most narrow part of airway (below
vocal cords)
PHYSIOLOGY
Smaller floppy upper airway more likely to
obstruct and more susceptible to swelling
Resistance is inversely proportional to
radius
R 1/r4th power
Small decrease in airway size=large
increase in airway resistance
PHYSIOLOGY
Crying increases the work of breathing 32
times
Basal O2 requirement 2x that of adults
FRC (functional residual capacity) 40% of
adults
Only half the alveoli of adults
Overall, less reserve and faster desaturations
EQUIPMENT
Length based systems
Decrease errors
Eliminate remembering and completing
mathematical equations
Organize equipment
BROSELOW SYSTEM
EQUIPMENT
Self inflating bags smallest 450ml
Pop off valves that may have to be closed
Newborn equipment different than peds (0
blades, <50mm oral airways, 250ml BVM, 3-0
tubes)
RESPIRATORY
DISTRESS
Rapid 30 second assessment
T one
I nteractive
C onsolablity
L ook/track
S peech/cry
RESPIRATORY
DISTRESS
Altered mental status
Nasal flaring
Head bobbing
Accessory muscle use
Grunting
RESPIRATORY
DISTRESS
You must undress the patient
Retractions
Substernal
Intercostal
Supraclavicular
Suprasternal
RESPIRATORY
DISTRESS
Infants are nose breathers
Secretions can impeded air flow
Bulb syringe nasal suction may alleviate this
RESPIRATORY FAILURE
Impending respiratory arrest
All of the above signs diminish
Respiratory rate diminishes
Mental status diminishes
Child becomes quiet
Mottling may develop
TECHNIQUE
MEDICATIONS
Succinylcholine
Dose higher at 1.5mg/kg
Etomidate
0.3mg/kg
Fentanyl
1-3mcg/kg consider for age >10 and head injury
TECHNIQUE
MEDICATIONS
Vecuronium
0.1mg/kg
Rocuronium
1mg/kg
TECHNIQUE
MEDICATIONS
Atropine
Routine use not recommended
Should be available and prepared in case it is
needed (more common in children <1)
0.02mg/kg
TECHNIQUE HEAD
POSITION
Sniffing position
Slight anterior displacement of neck (pulling chin
up)
Small infants may require elevation of shoulders
with a towel to counteract a large occiput flexing
head
Older children may require a towel under the
head
Goal is to align ear canal anterior to shoulders
Head tilt chin lift or Jaw thrust (trauma
patients)
Picture Fig 21-1 page
284
TECHNIQUE OXYGEN
SUPPLEMTATION
Oxygen may be delivered by
Blow by
Nasal cannula
Face mask
Forcing the child to struggle with nasal
cannula oxygen increase oxygen demand
Blow by may suffice
TECHNIQUE BVM
BVM alone may suffice for short
transports
Pediatric airway obstruction usually
amenable to BVM
The extra thoracic trachea is collapsible in
children, so with increased negative pressure
from inspiration during obstruction,
obstruction may become worse and BVM may
help
TECHNIQUE BVM
Don’t compress submental tissue
Hold angle of mandible
Use C-Clamp technique (solo)
Use 2 providers when possible
Don’t put pressure on eyes (causes vagal
response)
TECHNIQUE BVM
Normal tidal volume 8-10ml/kg
Watch for adequate chest rise
Squeeze-Release-Release to allow for
exhalation
Only use enough force to see chest rise
8-10 BPM code, 12-20 alive (monitor end
tidal CO2)
TECHNIQUE BVM
Avoid gastric insufflation
Avoid excessive peak inspiratory pressure
Ventilate slowly and watch for chest rise
Slight cricoid pressure (excessive will compress
trachea in peds)
TECHNIQUE BLADES
Follow Broselow guide
Miller straight blade better until about age 5
Lifts disproportionately large epiglottis out of
way
TECHNIQUE CRICOID
PRESSURE
Insufficient evidence to routinely recommend
cricoid pressure during intubation (as opposed to
BVM)
TECHNIQUE LAYNGEAL
MANIPULATION
Use as needed
Frequently:
B ackward
U pward
R ightward
P ressure
TECHNIQUE TUBES
Use Broselow guide
Be prepared with tubes 0.5mm larger and
smaller
Narrowest part of airway is below cords
If tight, use smaller tube
If large air leak, use larger tube or same
size tube with cuff
Small air leak, no worries if adequate
chest rise, O2 sat, end tidal CO2
TECHNIQUE TUBES
Cuffed tubes
Are OK
Cuff pressure needs to be monitored (20-25cm
water)
Don’t have to be inflated
In general, go a size smaller if using cuffed
tube for size <6.0
Too large a tube/too high cuff
pressure)=laryngeal tracheal stenosis
which can develop rapidly
TECHNIQUE TUBES
Tube insertion depth
Follow Broselow
3x size of tube (4.0 ETT=12cm insertion length
at teeth)
Secure tube, immobilize neck, as short
trachea predisposes to moving tube too
far in with neck flexion, and out with neck
extension
TECHNIQUE CONFIRM
PLACEMENT
Tube fogging
B/L breath sounds
Silent epigastrum
End Tidal CO2
Pulse ox
TECHNIQUE END
TIDAL CO2
Peds detectors up to 15kg (adult detectors have
too much dead space in circuit)
Adult detectors over 15kg (peds detectors will
cause too much resistance
TECHNIQUE END
TIDAL CO2
In cardiac arrest:
If <10-15mmHg, focus on improving CPR and
avoid over ventilation
An abrupt and sustained increase may signal
return of spontaneous circulation
In non arrest:
Titrate to clinical condition (35-45 unless head
injury/impending herniation 25-30)
POST INTUBATION
MANAGEMENT
Adequate sedation
Benzodiazepines
Diazepam 0.2mg/kg (max 10mg/dose)
Lorazepam 0.05mg/kg (max 2mg/dose)
Midazolam 0.1mg/kg (max 2mg/dose)
Opiates
Fentanyl 1-3mcg/kg (max 50mcg/dose)
Morphine 0.05-0.2mg/kg (max 5mg/dose)
Paralytics as needed
Rocuronium 1mg/kg
Vecuronium 0.1mg/kg
POST INTUBATION
MANAGEMENT
Problems
D isplacement of tube (confirm placement)
O obstruction of tube (pass suction catheter)
P neumothorax
E quipment failure (unhook from vent, check O2)
PITFALLS AND PEARLS
Performance anxiety
Equipment stocking and testing
Troubleshooting
Periodic training and practice
DIFFICULT AIRWAY
Infectious disease causes
Noninfectious causes including trauma
Congenital abnormalities
DIFFICULT AIRWAY
INFECTIOUS DISEASE
Epiglottitis
Croup
Retropharyngeal abscess
Bacterial Tracheitis
Ludwig’s angina
DIFFICULT AIRWAY
INFECTIOUS DISEASE
Small changes in airway diameter have a large
impact on airway resistance
Crying increases work of breathing 32 times
Don’t “over treat”
EPIGLOTTITIS
If stable, leave patient with parent in position of
comfort
2 person bag valve mask ventilation can be
sufficient
If needed, intubation can be attempted with a
smaller than predicted tube
Push on chest to try to see bubbles coming from
airway if visualization obstructed
One of the few indications for needle
cricothyrotomy if all else fails
CROUP
Subglottic narrowing
Tube may fit through cords, but then get snug
Use smaller than expected tube
BVM can work, but requires 2 people and possible
high pressure
DIFFICULT AIRWAY
NONINFECTIOUS DISEASE
Foreign body
Burns
Anaphylaxis
Caustic ingestion
Trauma
FOREIGN BODY
Conscious
Consider doing nothing if patient stable
Back blows less than age 1 year
Heimlich (age greater than 1)
Unconscious
BVM may work
Direct laryngoscopy
Removal of object
Push it down and move the tube back to normal position
Needle cricothyrotomy will only work if obstruction is
above the cricothyrotomy level (you should see it but
can’t remove it)
BURNS, ANAPHYLAXIS,
CAUSTIC INGESTIONS,
TRAUMA
If condition is decompensating and/or not
responding to treatment, consider early
intervention
Should consider medications first in anaphylaxis
CONGENITAL
ABNORMALITITES
Don’t try unless you have to
May be more reasonable to support until
respiratory failure/arrest has occurred
Treat for causes of respiratory distress
CONGENITAL
ABNORMALITITES
MICROGNATHIA
Small mandible reduces the space to which the
tongue and soft tissue can be displaced out of
your way
DIFFICULT AIRWAY
ADJUNCTS
LMA
Needle cricothyrotomy
Combitube/King LT
DIFFICULT AIRWAY
LMA
Can be used in all ages
In small infants more complications
Causes obstruction with relatively large
epiglottis
Easy to lose adequate seal with movement
Air leaks
Recommend inserting upside down and
rotating it as advanced back
Not for foreign bodies, caustics, burns
NEEDLE
CRICOTHYROTOMY
For use when you cant intubate or ventilate
For use in children <8-10 years old
Not helpful for croup or distal foreign bodies
NEEDLE
CRICOTHYROTOMY
Extend head, towel under shoulders
Identify landmarks
Insert catheter (14g) over the needle at a
30 degree angle directed toward feet
Aspirate air
Slide catheter off needle and remove
needle
Attach 3mm ETT adapter and begin BV
NEEDLE
CRICOTHYROTOMY
Will require excessive force due to small
catheter diameter
Pop off valve should be disabled
Does not protect airway
Does not allow for adequate ventilation, only
oxygenation
NEEDLE
CRICOTHYROTOMY
Complications
Inappropriate needle placement
Inadequate ventilation (hypercarbia and acidosis)
Obstruction of small catheter
Subcutaneous emphysema
NEEDLE
CRICOTHYROTOMY
TTV
For use >5 years
Supraglottic patency required to allow for
exhalation (air stacking)
Barotrauma
Start with 20 PSI and adjust to chest rise
Requires no more than of 1 second inspiration,
then 3 seconds to exhale
Nasal/oral airway should be placed as well
COMBITUBE/KING LT
Double/single lumen tube designed to be place in
esophagus
Must be 4ft tall for small Combitube
May not protect against aspiration
Not for caustic ingestion or significant
esophageal pathology