Paediatric Airway Emergencies

1. Paediatric Airway Emergencies DR. D. Mannion. Chairman Dept of Anaesthesia & Critical Care OLCH Crumlin IARNA 2010

2. Objectives • Why are children different? • Anatomy • Physiology • Routine management of paediatric airway • Common problems • Management of difficult airway. • Anticipated • Unanticipated IARNA 2010

3. Supra Glottic Narrow nares Large tongue Epiglottis large and floppy Larynx more anterior Larynx more cephalad C3 – C4 Sub Glottic Narrow cricoid ring Trachea 2-5 cm short Bronchi more horizontal Small cricothyroid membrane Mobile compliant trachea ANATOMY IARNA 2010

4. PHYSIOLOGY • Lung volume smaller in proportion • Metabolic rate is twice an adults • Greater VO2 6ml/kg v 3 ml/kg in adult • Vent requirement per unit lung is greater • Airway resistance is greater due to small airways • High respiratory rates IARNA 2010

5. Physiology – practical implications • Great for inhalational inductions • Great for maintaining inhalational anaesthesia BUT • If airway obstructed they rapidly desaturate. IARNA 2010

6. Also • Neonates obligate nasal breathers until 2-5 months of age. • Tonsils and adenoids appear at 2 years and reach max size at 4 – 7 years. Snoring, sleep apnoea and upper airway obstruction when unconscious. IARNA 2010

7. COMMON DIFICULTIES • Position • Neutral position – small role under shoulders • Over extended neck worsens obstruction • Mask • Shouldn’t occlude nostrils, pressure on eyes • Chin Lift • Pressure on submental tissues occludes airway as tongue is pushed up into palate. • Jaw thrust – most effective manouvere IARNA 2010

8. LARYNGOSCOPY • Straight blade picks up epiglottis • Mobile larynx means cricoid pressure can considerably improve the view. • Vocal cords angled – anterior commisure may hitch tracheal tube – rotate it. • Most ET tubes are marked with black line to indicate how far to insert. IARNA 2010

9. Microlaryngoscopy • Inhalational technique • IV anaesthesia technique IARNA 2010

10. Common problems • Laryngospasm • UAO • Laryngeal obstruction • Epiglottitis/Papillomatosis/Vocal cord palsy • Foreign body • Sub glottic oedema/ Tracheomalacia • Mediastinal mass • Difficult intubation IARNA 2010

11. Upper airway obstruction • Laryngomalacia – commonest congenital stridor IARNA 2010

12. Presents 2 weeks Stridor feeding difficulties Gone by 18 – 24 months Laryngomalacia IARNA 2010

13. Laryngospasm BCH experience • 210 cases over 6 years • Inadequate depth of anaesthesia usual factor • Commonest < 6 years and < 1 yr • Experience of anaesthetist influenced occurence IARNA 2010

14. Laryngospasm - treatment • CPAP & O2 successful in third of cases • Deepen anaesthesia - Propofol – over 70% of cases. • Muscle relaxant IARNA 2010

15. Laryngospasm - prevention • Adequate depth of anaesthesia • ALWAYS HAVE IV BEFORE LARYNGOSCOPY • Spray cords with local if working on airway • Remove LMA early and ET either anaesthetised or awake. IARNA 2010

16. Laryngeal obstruction • Epiglottitis • Papillomatosis • Haemangioma • Laryngeal web • Vocal cord palsy IARNA 2010

17. HPV 6 & 11 Repeated microdebriement Cidofovir ?? Don’t intubate. Discard circuit after single use. Papillomatosis IARNA 2010

18. Laser Tracheostomy Steroids B Blockers Propranolol Acetbutalol Haemangiomas IARNA 2010

19. Vocal cord paralysis • Idiopathic, neurological, iatrogenic, birth trauma. • Stridor, feeding difficulties • 70% resolve. IARNA 2010

20. Foreign Body IARNA 2010

21. FB – post removal IARNA 2010

22. Laryngeal Cleft IARNA 2010

23. Laryngeal Cleft – Grade 1 IARNA 2010

24. IARNA 2010

25. IARNA 2010

26. Difficult airway • Difficult intubation • 0.08% healthy & 0.42% all children • Anaesthesiology 2007;107:A1637 • 0.095% < 16 yrs & 0.24% < 1 yr • Paediatr Anaesth 2004. • Cant ventilate • <0.02% difficult but never impossible. Anaesthesiology 2007;107:A1637 • Adults 0.15% difficult to ventilate • Anaesthesiology 2009 110:891 IARNA 2010

27. Diff ventilation • More common in less experienced hands • Anatomical • Functional • Laryngospasm • Light anaesthesia • Inflated stomach • Bronchospasm. IARNA 2010

28. Difficult intubation/ventilation • Anticipate • Have a plan A, plan B and C if necessary. • Maintain oxygenation • Tracheostomy • DON’T PANIC!!! • GET HELP IARNA 2010

29. ANTICIPATE • Congenital • Cranio-facial abn – Pierre-Robin etc. • Laryngotracheal – web, stenosis, malacia • Structural • foreign body, stenosis, burns, oedema, vascular. • Inflammatory • Croup, epiglottitis, papillomatosis, abscess • Neoplastic • Cystic hygroma, tumours. IARNA 2010

30. Assess – History • Snoring • Apnoea • Stridor • Inspiration (extrathoracic e.g laryngomalacia) • Expiration (intrathoracic) • Blue • Hoarse • Daytime somnolence? • Previous anaesthetic? • Preferred position sitting? IARNA 2010

31. Assess - physical • Failure to thrive – sleep disordered breathing • Caucasian v African children - UAO • Dyspnoea • Chest retractions • Drooling saliva • Weak cry • Dysmorphic facies IARNA 2010

32. Additional • Lung function tests – spirometry FEV1 • Radiology • AP & lateral of neck and thoracic inlet • CT & MRI • Awake Endoscopy • Anatomy + dynamic views • Sleep studies IARNA 2010

33. Anaesthesia • Inhalational induction – technique of choice • IV – occ used but in small doses so spontaneous respiration is maintained • Always secure IV access before attempting intubation. • Neuromuscular blockers best avoided • Time !!! IARNA 2010

34. Difficult intubation • Is airway secure? i.e oxygenation & ventilation • Is position correct? • Is roll present? Is it too big? • Use cricoid pressure • How long do I attempt it? – assistant role! • How many attempts – avoid trauma • Do I need to intubate? – wake up or tracheostomy? IARNA 2010

35. Laryngeal mask airway • Definitive airway • May be used to ventilate child • As conduit for fibreoptic intubation • Temporary airway until surgical airway secured IARNA 2010

36. Alternative laryngoscopes • Mc Coy • Macintosh • Seward • Paediatric video laryngoscope • Storz & Glidescope • May assist in intubation • Some reports of benefit • Early in their use IARNA 2010

37. Fibreoptic intubation • Child must be anaesthetised, oxygenated and stable to allow time for intubation. • ET in nostril or special mask. • Topical anaesthesia • 4% lidocaine • Oral, via nasal ET tube, or via LMA. • Try to maintain skills. IARNA 2010

38. Fibreoptic intubation oral, nasal. • Load tube onto scope • Nasoendoscopes 2.2 – 2.5 mm • no suction • should take any size tube. • Bronchoscopes 2.8 – 4 mm. • Can take size 3.5 ET tube. • Have suction • May use suction port to deliver local IARNA 2010

39. OLCHC Plan • Inhalational induction & IV access • Anaesthetic intubation • Intubate with MLB setup (Parsons) • Rigid bronchoscope & bougie • Maintain airway with mask or LMA • Tracheostomy IARNA 2010

40. Tracheostomy – when ? • Cant intubate • Can intubate but with much difficulty • Extubation may cause problem IARNA 2010

41. Cant intubate, cant ventilate • Very rare • Needs structured protocol to manage IARNA 2010

42. Pneumothorax Surgical emphysema Vascular injury Haemorrhage Haematoma False passage Aspiration Pulmonary barotrauma Subglottic oedema Subglottic stenosis Oesophageal perforation Infection Cricothyroidotomy complications IARNA 2010

43. Cricothyroidotomy • APLS/Books percutaneous needle or surgical cricothyroidotomy • In practice – trachea may be only mm in diameter therefore cricothyroidotomy very difficult IARNA 2010

44. Principles for paediatric diff intubation • Maintain oxygenation & ventilation • Multiple and prolonged attempts at intubation cause morbidity – therefore limit to 4. • Blind techniques have a high failure rate and cause trauma. • Awaken patient and postpone surgery? IARNA 2010

45. Principles for paediatric cant intubate cant ventilate scenario • Use 2 person technique to ventilate • LMA – frequently rescues situation • If above fail – proceed to surgical airway. IARNA 2010