Pediatric Airway Management

1. Pediatric Airway Management Jennifer Oliverio RRT, BSc Clinical Educator Respiratory Services Alberta Children’s Hospital

2. A & P Characteristics of Newborn Respiratory System • Infant lung is a unique structure not a mini- adult lung • Airways, distal lung tissue and pulmonary capillary bed continue to grow and develop after birth • General pattern is laid down at birth but upper and lower airways continue to change • Alveoli development complete and adult anatomy by 8-10 years of age • Ossification of ribs and sternum complete by 25 years of age

3. Nose • Obligatory nasal breathing • Poor tolerance to obstruction • Relatively Large • Neck extension may not relieve obstruction Tongue

4. Head • Relatively large • Anterior flexion may cause airway obstruction • Relatively large and U- shaped • More susceptible to trauma • Forms more acute angle with vocal cords Epiglottis

5. Larynx • More anterior and cephalad • Intubation more difficult • Narrowest portion of airway • ↑ resistance with airway edema or infection • Acts as “cuff” during tracheal intubation Cricoid

6. Trachea • Small diameter (6mm), high compliance • ↑ resistance with airway edema or infection • Collapses easily with neck hyperflexion or hyperextension • ↑ closing capacity • No pores of Kohn • ↑ air trapping and ↓ collateral circulation of air Alveoli

7. Pulmonary Vessels • ↑ pulmonary vascular resistance (PVR) • Very sensitive to constriction by hypoxia, acidosis and hypercarbia • ↑ compliance due to weak rib cage • ↑ A-P diameter • Horizontal ribs • Breathing is all diaphragmatic • FRC determined solely by elastic recoil of lungs • Chest wall collapses with -ve pressures Chest Wall

8. WOB • Weak resp muscles • ↑ RR = early sign of resp distress • Response to ↓ O2/ ↑ CO2 minimal • Tolerates hypoxia poorly Regulation of Breathing

9. Airway assessment • Best to 1st look from afar. Infants and small children don’t like strangers hard to assess baseline after they are upset. • 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?

10. Airway Management • 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

11. Oral & Nasopharyngeal Suctioning • Clean technique • Negative pressure of 80 to 120 mmHg. Test suction level on regulator prior to suctioning • Nasal and oral suction can be performed with same catheter • May result in hypoxia, ↓ HR (vagal), bronchospasm, larygospasm, atelectasis

12. Suction supplies • Clean gloves • Suction regulator, canister, tubing • Normal saline in cup • Yankauer and appropriate suction catheter

13. Nasopharyngeal Suction • Measure length from pt’s earlobe to tip of nose • Keep pass <10 sec. • Document: pt assessment prior to procedure, time of procedure, amount and type of secretions, pt’s response

14. Positionning • If pt has preferred position let them remain in that position e.g. tripod • Repositioning can greatly improve airway patency • Manual airway maneuvers can also help open the airway (head tilt-chin lift/ jaw thrust)

15. Oral Pharyngeal Airways (OPA) • Only for use in UNCONSCIOUS pt with no intact cough/gag reflex • Holds tongue and soft hypopharyngeal structures away from posterior pharynx • Still need good head and jaw position to maintain airway patency • Suction airway prn • Never tape in place

16. Choosing correct OPA • Place OPA against side of face. With flange at the corner of the mouth the tip should reach angle of the jaw • Too small: will not adequately displace tongue • Too large: may obstruct larynx and/ or interfere with mask fit if BVM required

18. Nasopharyngeal Airways • Soft plastic pre-made or shortened ETT • Provides unobstructed path for airflow between nares and pharynx • Can use in conscious/ semi-conscious pt • Small internal diameter so must be evaluated frequently and suctioned prn to maintain patency

20. If these don’t work… • Pt may require more advanced interventions to establish a patent airway • CPAP • Intubation

21. Breathing • RR • Effort • Tidal volume • Airway and lung sounds • SpO2

22. RR • Normals As per PALS

23. RR • Best to evaluate prior to hands-on assessment • Excitement, anxiety, exercise, pain, fever, agitation can all ↑ RR • ↓ RR with acutely ill child or with ↓ LOC = ++ cause for concern • > 60 in any age is cause for concern

24. Effort • Signs of ↑’d respiratory Effort • Nasal flaring • Chest retractions • Head bobbing • Chin lifts and neck extends during I • Chin falls forward during E • Seesaw respirations • Chest retracts and abdomen expands during I, reversed during E • Very Inefficient= quickly leads to fatigue • Grunting • Child exhales vs partially closed glottis in an effort to keep small airways open

25. Auscultation • Same landmarking and principals as with adults • BUT…smaller size and sound is transmitted much more easily throughout the infant chest.

26. Bag-Mask Ventilation • Indicated when the pt’s spontaneous breathing effort is inadequate despite patent airway • Can provide adequate oxygenation and ventilation until definitive airway control is obtained • Can be as effective as ventilation through ETT

27. **Multiple Mask sizes available so choose the correct one**

28. Bagging Units • 3 sizes:

29. Testing the bagging unit • Check all components before use to ensure proper function. Ideally as part of your daily safety checks. • Occlude pt outlet and outflow, squeeze bag ensure no tears/leaks • Check that PEEP valve works (2L) • Ensure connection to wall O2 and adequate flow • Proper size mask with cuff inflated

30. Bagging • Position pt: sniffing position

31. Infants: Want exterior ear canal to be anterior to the shoulder In our experience at ACH we find a shoulder roll works best for positioning infants and small children

32. Bagging • Position pt: sniffing position • Open airway and seal mask to face using E-C technique. You may need OPA.

34. Bagging • Position pt: sniffing position • Open airway and seal mask to face using E-C technique. You may need OPA. • Squeeze bag with other hand to deliver tidal volume and produce chest rise. Careful to not over-ventilate!

35. 2 person BMV • One person uses both hands to open airway and maintain tight mask-to-face seal • 2nd person bags

36. Monitor effectiveness of Ventilation • Visible chest rise with each breath • SpO2 • ETCO2 • HR • BP • Pt responsiveness • Air entry on auscultation

37. If ventilation is not effective… • Reposition pt. Reposition airway. OPA. • Verify proper mask size and placement • Suction airway • Check O2 source and flow • Check bag and mask for function/leaks • Treat gastric inflation

38. Indications for intubation • Respiratory distress • Apnea • Self-extubation • Upper airway obstruction or the potential to develop upper airway obstruction • Actual or potential decrease in airway protection (compromised neurological function) • Need to eliminate/ reduce WOB (e.g. cardiac pt) • Inadequate ventilation and/or oxygenation

39. Preparing for Intubation • Appropriate ETT for >1 yo: (age/4) + 4 Term infant: 3.0-3.5 ID 6 mo: 3.5-4.0 ID 1 yo: 4.0-4.5 ID • Cuffed ETT’s for pt’s > 8 yo • If you anticipate need for high PEEP or PIP may want to use cuffed ETT with <8 yo. Use ½ size smaller ETT. • Remember SOAPME

40. SOAPME Suction equipment: yaunkauer, catheters, regulator/canister/tubing, Oxygen: O2 flowmeter, preoxygenate 2-3 min, manual resuscitator bag with mask Airway equipment: ETT, stylet, syringe (cuffed ETT), laryngoscope and blade, lubricating gel, OPA Position, pharmacy, personnel: supine, rolls for positioning, bed height up Monitors ETCO2 detector

41. Post-Intubation • ETCO2 assessment for confirmation of placement • Auscultation for bilateral air entry • Placement of ETT documented • ETT secured with tapes • CXR to confirm placement • Place pt on ventilator

42. Acute deterioration post-intubation • Remember DOPE

43. Tube Position • Remember: Endotracheal tube position follows chin • Pt positioning ++ important. Often need shoulder roll to keep chin neutral. • CXR need to be done with neutral, midline head position (RRT should be called) • Chin low- tube low • Chin high- tube high

44. Uncuffed ETT’s • May have issues with leak • Better success with Pressure modes of ventilation with a tube leak • Position of pt can affect amount of leak • If having difficulty with ventilation or oxygenation may need to upsize ETT or Δ to cuffed ETT • Short term fix: NS soaked nasal packing packed around ETT. DO NOT CUT the gauze.

45. Cuffed ETT • Important to assess cuff inflation Qshift • > 8 yo can follow adult VAP guidelines • 25-30 cm H2O inflation pressure • < 8 yo MOV with pressure < 20 cm H2O often quite a bit lower than 20 • Cuff is circumferential in a growing airway!

46. Suctioning ETT • Suction frequency depends on ETT size and pt needs: • 4.0 i.d. and smaller- a minimum of Q8H unless otherwise ordered • 4.5 i.d. and greater- prn or as ordered • All pt’s need for suction should be assessed hourly and prn Sterile suctioning • Suction depth should only be 0.5 cm past the end of ETT • Determine suction depth by using suction guide or match number on catheter to number on ETT and advance 0.5 cm.

47. Assessing need for suction • Clinical assessment of pt will determine frequency of suctioning. Many factors influence the need for suction including but not limited to: • ETT Size • Changes in vital signs • Adventitious breath sounds • ↓ breath sounds/ chest movement • ↓ SpO2 • Visible secretions in ETT • Respiratory distress • Coughing • ↑TcCO2/ EtCO2 • ↑ PIP • Worsening ABG/CBG

48. Selecting suction catheter • 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

49. Wall suction Use lowest possible setting

50. Instillation • Normal saline unless otherwise ordered • Should occur prn not routinely • For <10 FR you can use sterile NS syringe as there is no one-way valve in instillation port. For >12 Fr you will need pink NS nebule. • Recommended amounts: *total volume is especially important to limit and document in infants and small children