Transcript Airway Transport

Airway Management in
Transport
Toni Petrillo-Albarano, MD
Pediatric Critical Care Medicine
Children’s Healthcare of Atlanta
at Egleston Children’s Hospital
Objectives
 Overview
of the differences between
the pediatric and adult airway
 Intubation of the pediatric patient
Anatomic Considerations in
Pediatrics
 Relatively
Large Occiput
 Large Tongue
 Larynx is anterior and superior
 Epiglottis may be floppy with acute
angle
 Narrowest portion is cricoid cartilage
The Basics
The airway in any patient can be:
 Physiologic
• maintained easily or with effort by the
patient
 Maintainable
• with some assistance/positioning
 Invasive
Intervention
• oral airway, nasal trumpet, or intubation
The Basics
To assist patient’s in maintaining an
airway:
 Clear mouth
 Position head
 Consider Airway adjuncts
Proper Positioning
A jaw thrust or head tilt
maneuver will position the
tongue so that it will not
obstruct the airway
Remember that a child has a
relatively large tongue
compared to an adult
In infants it is possible to
hyperextend the neck too much
and cause the soft tissue to
obstruct the airway
Nasal Trumpet
A nasal trumpet can
be a useful adjunct
possible for the
trumpet to be too long
or too short
Oral Airway
An appropriately placed
oral airway will pull the
tongue forward and
provide an unobstructed
airway
If the oral airway is too
long, it will stimulate a
gag. If it’s too short, it
will not lift the tongue.
Airway Adjuncts
The use of airway adjuncts, such as the nasal
trumpet and oral airway, will only provide an
adequate airway.
The patient must have reasonable respiratory
effort.
If the patient is unable to maintain adequate
ventilation, he/she should be bagged or
proceed to endotracheal intubation.
Indications for Intubation
1. Unable to protect airway
2. Inadequate ventilation
3. Hypoxemic respiratory failure requiring
positive pressure
4. Therapeutic (e.g. Hyperventilation in
head injury)
Difficult Airway Considerations
 Short,
muscular neck
 Receding mandible
 Protruding incisors
 Uvula not visualized
 Limited TMJ mobility
 Limited C-spine mobility
What do you need?
Monitors -- cardiac and pulse oximetry
Suction -- Yankauer or catheter
Machine -- ventilator or bag/mask
Airway -- Endotracheal tube
Intravenous -- peripheral or central line
Drugs -sedation/analgesia/paralysis/atropine
Laryngoscopes
Straight
 Curved
 Fiberoptic

Proper visualization



The laryngoscope
should be used to lift
“up and out”. Do not
rock back on upper
teeth.
Curved blade tip is
placed in vallecula and
will lift epiglottis away
from airway.
Straight blade tip is
used to hold the
epiglottis from beneath.
Proper ETT Size
Newborn - 6 months
6 months - 1 year
> 1 year
3.5
4.0
4 + age
4
Intubation Procedure
Prepare Equipment
 Position patient

• Table height
• “Sniffing” position

Pre-oxygenate
• 4 max breath in 30 sec
• 100% O2 for 3-5 min

Induction agent
• sedative/analgesic

Neuromuscular
blocker

Intubation
• Laryngoscope in L hand
• Insert on R of mouth and
sweep tongue to L
• Advance in midline until
epiglottis visualized
• Advance tip of blade
– into vallecula (curved
blade)
– beneath epiglottis
(straight blade)
• Lift towards feet
– “up and out”, “Never
Lever”
Rapid Sequence Intubation
Done when immediate airway stabilization is
required or the patient has a “full stomach”
• has eaten
-- pregnancy
• trauma
-- abdominal mass
• GER
-- misc
• bowel obstruction
 Expedited with rapid acting drugs and
avoidance of bag mask ventilation

Rapid Sequence Intubation

Procedure
• Pre-oxygenate
• Rapid Induction Agents
• Rapid Acting Neuromuscular Blocker
• Sellick’s Maneuver
• Intubate
• Check breath sounds, inflate cuff (if
applicable)
• Release cricoid pressure
Sellicks’ Maneuver
 Cricoid
Pressure
 Closes esophagus against the vertebral
column
 protects against passive regurgitation
 DO NOT release until airway is secure !
Intubation Medications
Goals:
 Provide adequate intubation conditions
• airway easily visualized
• patient comfort (not fighting procedure)
 Avoid
complications
• hemodynamic instability
• ICP in head injury
Atropine
 Blunts
vagal response that can cause
bradycardia and dries oral secretions
 Dose = 0.02 mg/kg (min 0.1 mg)
 Adverse effects
•
•
•
•
tachycardia
mydriasis
atropine flush
disorientation
Benzodiazepines
 Effective
in providing anxiolysis and
amnesia
 Onset and duration vary between
midazolam, lorazepam, and diazepam
 Dose = 0.1 mg/kg
 Adverse Effects include: hypotension
and myocardial depression
Fentanyl
 Sedative/Analgesic
 Dose
2-5 mcg/kg
 Rapid Onset and short duration -- thus
an excellent intubation med
 Virtually no CV side effects
Ketamine
 PCP
Derivative, Dissociative Hypnotic
 Rapid Onset and short duration
 Dose = 1-2 mg/kg IV or 2-4 mg/kg IM
 Increases HR, and BP and thus may be
ideal for the patient with shock.
 Increases cerebral metabolic rate and
ICP and thus not a good choice in head
injury or seizure
Thiopental (Pentothal)
 Dose
= 2-5 mg/kg
 Max Effect in 60 seconds
 Sedative Hypnotic that decreases
cerebral metabolic rate and ICP
 Hypotension and Myocardial Depression
are possible adverse effects
Etomidate
 Ultra
short-acting non-barbiturate
hypnotic
 rapid induction of anesthesia with
minimal cardiovascular effects
 0.2-0.6 mg/kg over 30-60 seconds
 Peak effect: 1 minute
 Duration of action: 3-5 minutes
 Can cause adrenal suppression
Neuromuscular Blockers
 Recommend
•
•
•
•
•
only rapid acting agents:
Succinylcholine - dose = 1 mg/kg IV
Rocuronium - dose = 0.6-1.2 mg/kg IV
Vecuronium - dose = 0.1-0.3 mg/kg IV
Mivacurium - dose = 0.2 mg/kg IV
Atracurium - dose = 0.2 mg/kg IV
Recommended Intubation
“Cocktails”

Controlled Intubation
•
•
•
•

Fentanyl & Lorazepam or
Etomidate
Vecuronium/Rocuronium
+ Atropine
Head Injury
•
•
•
•
Pentothal or Etomidate
Lidocaine 1 mg/kg IV
Vecuronium
Atropine

Septic Shock
• Atropine
• Ketamine
• Rocuronium/Vecuronium

Status Asthmaticus
•
•
•
•
Atropine
Ketamine
Lorazepam
Rocuronium/Vecuronium
Physiologic Response to
Intubation
 Airway
Reflexes
• Laryngospasm
• Cough
• Gag
 Cardiovascular
Reflexes
•
•
•
•
Sinus bradycardia
Tachycardia
Hypertension
Dysrhythmias
Assessing ETT placement
 Direct
visualization
 ETCO2 (digital readout or color
paper)
 Chest rise
 Auscultation (be certain to confirm
absence of gastric breath sounds)
 ETT vapor (unreliable)
 Chest X-ray
Monitoring on Transport
Physical
Exam
EKG monitor
Pulse oximeter
ETCO2 Monitor
Reevaluate Frequently
Capnograms
Normal
Zero baseline
 Rapid, sharp up rise
 Alveolar plateau
 Well-defined end-tidal
 Rapid, sharp down stroke

A—B
B—C
C—D
D
D—E
Deadspace
Dead space and alveolar gas
Mostly alveolar gas
End-tidal point
Inhalation of CO2 free gas
Capnography
Sudden loss of waveform
Esophageal intubation
 Ventilator disconnect
 Ventilator malfunction
 Obstructed / kinked ETT

Capnography
Decrease in waveform
Sudden hypotension
 Massive blood loss
 Cardiac arrest

Hypothermia
 PE
 CPB

Capnography
Gradual increase in waveform
 Increased
body temp
 Hypoventilation
 Partial airway obstruction
 Exogenous CO2 source (w/laparoscopy/CO2
inflation)
Capnography
Sudden drop – not to zero
 Leak
in system
 Partial disconnect of system
 Partial airway obstruction
 ETT in hypopharynx
Capnography
Sustained low EtCO2
Asthma
 PE
 Pneumonia

Hypovolemia
 Hyperventilation

Low ETCO2, but good plateau
40
30
Capnography
Cleft in alveolar plateau
 Partial
recovery from neuromuscular
blockade
40
Capnography
Transient rise in ETCO2
 Injection
of bicarbonate
 Release of limb tourniquet
40
Capnography
Sudden rise in baseline
 Contamination
of the optical bench –
need to recalibrate
40
Questions
 1.
Which drug is not used in the
intubation of a head injury patient?
•
•
•
•
A. Ketamine
B. Thiopental
C. Lidocaine
D. Etomidate
Question

2.Capnograph
represents
A. Esophageal
intubation
 B. Ventilator
disconnect
 C. Obstructed /
kinked ETT
 D. All of the above

Question
 3.
Appropriate ETT size for a 6 year old
calculated by formula is?
•
•
•
•
A. 6.0
B. 4.5
C. 5.0
D. 5.5
Question
 4.
True or False:
• Curved blade tip is placed in vallecula and
will lift epiglottis away from airway
Question
 5.
All of the following are indications for
intubation except:
• A. Unable to protect airway
• B. Inadequate ventilation
• C. Hypoxemic respiratory failure requiring
positive pressure
• D. GCS 10