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Outline. Differences in pulmonary physiology and airway anatomy Mask ventilation and intubation techniquesEvaluation of the upper airwayPediatric laryngoscope bladesSizing of ETT and depth of ETTPredictors of difficult intubationManagement of the difficult airway. Pulmonary Physiology Differences.
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1. Management of the Pediatric Airway Paul W. Sheeran, MD
Dept of Pediatrics
Division of Critical Care
Dept of Anesthesiology &
Pain Management
UTSW Medical Center
2. Outline Differences in pulmonary physiology and airway anatomy
Mask ventilation and intubation techniques
Evaluation of the upper airway
Pediatric laryngoscope blades
Sizing of ETT and depth of ETT
Predictors of difficult intubation
Management of the difficult airway
3. Pulmonary Physiology Differences Compliant chest wall
Airway collapse at low lung volumes
Low FRC (desaturate quickly)
High oxygen consumption (6-10 cc O2/kg/min)
TV same; minute ventilation increased
4. Airway Anatomy Differences Relatively larger head and tongue
More cephalad larynx (C3-4 vs. C5-6)
More anterior larynx
Narrowest part of the airway: cricoid cartilage
Long epiglottis (floppy, omega shaped)
Easily compressed trachea
5. Adult Glottis
6. Pediatric and Adult airways
7. Mask Ventilation Technique
8. Sizing of Oral Airway
9. Intubation Technique for Neonate
10. Induction Techniques Mask induction (most children):
Place monitors
8% sevoflurane in oxygen/nitrous oxide (5L/2L)
When asleep: decrease sevoflurane to 4-6%, place PIV, 100% O2, administer NMB, and intubate
IV induction (RSI, adolescents, in situ PIV):
Place monitors and pre-oxygenate
Administer: Pentothal 6 mg/kg or propofol 3 mg/kg and NMB
Intubate
11. Upper Airway Evaluation Mouth opening
Size of the jaw
Thyromental distance
Mallampati classification
Class I: entire uvula visible
Class II: part of uvula hidden by tongue
Class III: only soft palate visible
Class IV: only hard palate visible
Neck range of motion (extension AO joint)
12. Mallampati Classification
13. Cormack and Lehane Grades
14. Miller laryngoscope blades
15. Phillips laryngoscope blades
16. Mac laryngoscope blades
17. Pediatric Laryngoscope Blades Types:
Miller
Philips
Mac
Newborn: Miller 0
1 month - 1 year: Miller 1
13 years: Philips 1
4-8 years: Mac 2
>8 years: Mac 3, Philips 2, or Miller 2
18. Difficult Airway due to Dysmorphia Decreased mandibular space (limited mouth opening)
Micrognathia, retrognathia, mandibular hypoplasia
Pierre- Robin, Treacher Collins
Decreased head extension (RA, Klippel-Feil)
Increased tongue size or space-occupying lesion (e.g., cystic hygroma)
19. Guides for Proper ETT Sizing ETT size:
Newborn: 3.5 mm
4 months-1 year: 4.0 mm
Older child: 4 + (age in years/4)
Depth of ETT
Direct visualization (2nd notch)
ETT ID X 3
Loss of breath sounds (carina), pull out 2 cm
Cuff palpable in sternal notch
20. Treacher Collins Syndrome
21. Treacher Collins Syndrome
22. Klippel-Feil Syndrome
23. Hunters Syndrome
24. Hunters Syndrome
25. Other Indicators of Difficult Airway Burns to the face and neck
A history of radiation to the head and neck
A history of difficult intubation (i.e., read old anesthesia records if available)
26. Other Causes of Difficult Intubation Oral bleeding and swelling (e.g., mucositis, Stevens Johnson Syndrome, or recent T&A)
Copious oral secretions (e.g., RSV, ARDS, pulmonary hemorrhage)
Severe cardiac dysfunction (e.g., myocarditis, sepsis)
27. Difficult Airway Management Anticipate problems:
Call for help
Place PIV pre-op
Administer glycopyrolate (10 mcg/kg IV or IM) one hour prior to intubation
Keep patient spontaneously breathing (no NMB)
Techniques
Fiberoptic intubation (FOI)
LMA placement alone (no ETT)
LMA placement followed by FOI
Light wand-assisted oral intubation
28. Acquired Difficult Airway Epiglottitis/supraglottitis
Croup
Foreign body
Trauma
29. Epiglottitis/supraglottitis Acute inflammation of the epiglottis, aryepiglottic folds, arytenoids, and supraglotis
School-aged child presents with high fever, drooling, and inspiratory stridor
Causes: bacteria or caustic ingestion
Do not examine with a tongue blade
Take to the OR
Mask or IV induction without paralysis
Rigid bronchoscopy by ENT
30. Croup Gradual onset of inspiratory stridor and barky cough in young children (<3 years)
Subglottic narrowing (steeple sign on CXR)
Treatment:
Cool mist
Nebulized racemic epinephrine
Intubate if patient is in respiratory failure (smaller ETT than expected is typically needed)
31. Foreign Body Aspiration Young child with either
Acute h/o choking
Chronic h/o pneumonia or refractory wheezing/cough
Stable patients may be X-rayed
Unstable patients: intubated and then taken to the OR
For esophageal FB: RSI, intubation, and esophagoscopy
For laryngeal FB:
Mask or IV induction (without NMB)
Rigid bronchoscopy by ENT surgeon
32. Upper Airway Trauma Neck trauma may cause laryngeal and/or tracheal injuries
Presenting symptoms: SQ air, neck swelling, hypoxia
If the patient is in extremis in the E.R.
IV ketamine and glycopyrolate
Intubate orally
Confirm ETT location prior to NMB
If the patient is stable, then take to the O.R.
Mask or IV induction without paralysis
Tracheotomy by ENT
Oral intubation is controversial
33. Summary Pediatric patients have a small FRC and increased O2 consumption: pre-oxygenate with CPAP
It is imperative to evaluate the airway prior to administering paralytic agents
Difficult intubation associated with micrognathia, decreased head extension, and a large tongue
Problems with patients with a difficult airway should be expected: Dont go down alone