the pediatric airway: they re not just little adults

1. The Pediatric Airway:�They�re not just little adults!� Mark Byrne, MD Dept of Emergency Medicine Boston Medical Center April 27, 2010

3. Objectives Frame in terms of differences from adult airway Review of key anatomy and physiology Overview of rescue airway techniques and devices

4. Resources

5. Pediatric Intubation Disadvantages Age-related dosing, equipment size Anatomic, physiologic differences from adults Inexperience Kids aren�t supposed to get sick, don�t have the option to fail The pediatric airway is infrequently encountered, especially for the adult EM physicianKids aren�t supposed to get sick, don�t have the option to fail The pediatric airway is infrequently encountered, especially for the adult EM physician

6. Pediatric Intubation Advantages More predictable anatomy Fewer �difficult� airways Obesity, joint mobility, dentition Pediatric airway tends to be more �consistent� Also, adult EM deal with airway, intubation on a more frequent basisPediatric airway tends to be more �consistent� Also, adult EM deal with airway, intubation on a more frequent basis

7. Anatomy

8. Anatomy Pediatric <2 years old ? Transition ? Adult >8 years old Gradual transition from Pediatric to Adult airway during years 2 through 8 After age 8, kids are more akin to �small adults�Gradual transition from Pediatric to Adult airway during years 2 through 8 After age 8, kids are more akin to �small adults�

9. Pediatric vs. Adult

10. Pediatric vs. Adult

18. Pediatric vs. Adult

19. Anatomy Large tongue Prone to airway obstruction

20. Airway adjuncts Never truly failed bagging until oral airway and bilateral nasal airways placedNever truly failed bagging until oral airway and bilateral nasal airways placed

21. Airway adjuncts Incorrect sizes may worsen BVM ventilation

22. Anatomy Large tongue Prone to airway obstruction Tongue control may be difficult during laryngoscopy

24. Pediatric vs. Adult

25. Anatomy Long, �floppy� epiglottis Straight blade (e.g. Miller)

27. Pediatric vs. Adult

30. �Anatomical� cuff�Anatomical� cuff

31. Pediatric vs. Adult

32. Anatomy Short trachea Depth = Beware tendency to push too far down Right mainstem intubation is common pitfall Better visualization when passing a cuffless tubeRight mainstem intubation is common pitfall Better visualization when passing a cuffless tube

34. Pediatric vs. Adult

35. Equipment

36. Equipment Appropriate size is essential! Use length-based system (e.g. Broselow) Do NOT use memory or calculations

37. � Ron Walls, MD �Manual of Emergency Airway Management�

38. �Broselow tape� Adult med dosing and equipment sizes are �automatic� Pediatric age-related dosing leads to errors - lack of familiarity - added layer of complexity - less time for critical thinking Note pediatric ETCO2 detectorAdult med dosing and equipment sizes are �automatic� Pediatric age-related dosing leads to errors - lack of familiarity - added layer of complexity - less time for critical thinking Note pediatric ETCO2 detector

39. Equipment Endotracheal tube Size = 4 + age/4 � size above and below Tube size refers to internal diameter Use ETT size 3.0-3.5 for newborn, 2.5 for premieTube size refers to internal diameter Use ETT size 3.0-3.5 for newborn, 2.5 for premie

40. Equipment Laryngoscope Miller 1 <1 year old Miller 2 >2 year old Tube size refers to internal diameter May also use pinky finger as reference DON�T use (age+16)/4, use 4 + age/4, much simpler! Right mainstem intubation is common pitfallTube size refers to internal diameter May also use pinky finger as reference DON�T use (age+16)/4, use 4 + age/4, much simpler! Right mainstem intubation is common pitfall

42. Gastric distention can impede on diaphragm, limit lung insufflationGastric distention can impede on diaphragm, limit lung insufflation

43. Physiology

44. Mini-quiz Who desaturates most quickly? 1) Healthy adult 2) COPDer 3) Obese adult 4) Toddler

45. Mini-quiz Time to desaturate if pre-oxygenated 90% 0% Healthy adult 8mins 2mins COPDer 5mins Toddler 3.5mins 45sec Obese adult 2.5mins 1min

46. Physiology Kids desaturate fast!

47. Medications

48. Medications Succinylcholine Higher dose (2mg/kg) May induce bradycardia Consider Atropine (0.02mg/kg)

50. Medications Succinylcholine Higher dose (2mg/kg) May induce bradycardia Consider Atropine (0.02mg/kg) Risk of undiagnosed neuromuscular disorder May precipitate fatal hyper-K+

51. Medications Rocuronium High dose (1mg/kg) More rapid onset (60-75sec) Prolonged duration (40-60min) Reverse with Sugammadex

52. In phase III clinical trials in the US Approved for use in Europe?In phase III clinical trials in the US Approved for use in Europe?

53. Rescue airways

54. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

55. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

56. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

57. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

60. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

63. Rescue airways External laryngeal manipulation Bougie Fiberoptic (Glidescope, Airtraq) LMA Needle cricothyrotomy Pediatric bougie 10Fr instead of normal 15FrPediatric bougie 10Fr instead of normal 15Fr

64. � Ron Walls, MD �Manual of Emergency Airway Management�

65. Surgical airway Needle cricothyrotomy <8 years old Emergent pediatric intubation is a relatively uncommon occurrence, even in a large Pediatric Emergency Department Needle cric is a rare backup for an already infrequent procedure Classically in a can�t intubate, can�t ventilate situation such as epiglottitis (although failure to ventilate more likely 2/2 failure of technique in this situation) Also applicable to facial trauma, angioedema Likely not helpful in aspirated foreign bodyEmergent pediatric intubation is a relatively uncommon occurrence, even in a large Pediatric Emergency Department Needle cric is a rare backup for an already infrequent procedure Classically in a can�t intubate, can�t ventilate situation such as epiglottitis (although failure to ventilate more likely 2/2 failure of technique in this situation) Also applicable to facial trauma, angioedema Likely not helpful in aspirated foreign body

66. Cricothyroid membrane virtually nonexistent <3 years old May be entering the trachea as opposed to cricothyroid membraneCricothyroid membrane virtually nonexistent <3 years old May be entering the trachea as opposed to cricothyroid membrane

67. Needle cricothyrotomy Equipment 14g over-the-needle catheter 3mL syringe to 7.0mm ETT adapter 3.0mm ETT adapter Emergent pediatric intubation is a relatively uncommon occurrence, even in a large Pediatric Emergency Department Needle cric is a rare backup for an already infrequent procedure Classically in a can�t intubate, can�t ventilate situation such as epiglottitis (although failure to ventilate more likely 2/2 failure of technique in this situation) Also applicable to facial trauma, angioedema Likely not helpful in aspirated foreign body, croupEmergent pediatric intubation is a relatively uncommon occurrence, even in a large Pediatric Emergency Department Needle cric is a rare backup for an already infrequent procedure Classically in a can�t intubate, can�t ventilate situation such as epiglottitis (although failure to ventilate more likely 2/2 failure of technique in this situation) Also applicable to facial trauma, angioedema Likely not helpful in aspirated foreign body, croup

68. Jet Ventilation Extreme caution to avoid barotrauma Bag technique is preferable Excessive flow and pressures can lead to barotrauma Used only by those familiar with its use Start with low pressures (20 PSI) 0.5-1 sec burst of ventilation, followed by 3-4 sec exhalationExcessive flow and pressures can lead to barotrauma Used only by those familiar with its use Start with low pressures (20 PSI) 0.5-1 sec burst of ventilation, followed by 3-4 sec exhalation

69. Mini-case

70. Mini-case 18 month-old boy BIBEMS after sudden onset �noisy� breathing Pt anxious, inspiratory stridor, retractions, peri-oral cyanosis

71. Foreign body aspiration �Stable� �Unstable� �Crash�

72. Foreign body aspiration �Stable� IV access, O2, monitor* Consultants (ENT, anesthesia) Take to OR

73. Mini-case 2 Pt�s breathing begins to slow, appears to be tiring but still responsive

74. Foreign body aspiration �Unstable� Back blows/chest thrusts <1 yo Heimlich maneuver >1 yo

75. Mini-case 2 Pt progresses to apnea, now limp and unresponsive

76. Foreign body aspiration �Crash� Direct laryngoscopy, Magill forceps Attempt bagging

77. �Malleable� airway For same reason, need to be careful with cricoid pressure in infants and children, may compress larynx or trachea and obstruct airwayFor same reason, need to be careful with cricoid pressure in infants and children, may compress larynx or trachea and obstruct airway

78. Fixed obstruction

79. Foreign body aspiration �Crash� Direct laryngoscopy, Magill forceps Attempt bagging Intubate to push foreign body into either mainstem bronchus

80. Summary Know differences in anatomy compared to adults Understand importance of sizing, but use Broselow tape Kids desaturate fast! Remember risks of using Sux Know your rescue techniques, including needle cric

81. Thank you