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Pediatric Airway Management: An Update

Pediatric Airway Management: An Update. HANY EL-ZAHABY, MD Anesthesia, Ain Shams University. Five Cardinal Anatomical Features of Infant’s Larynx. 1- Higher Larynx

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Pediatric Airway Management: An Update

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  1. Pediatric Airway Management:An Update HANY EL-ZAHABY, MD Anesthesia, Ain Shams University

  2. Five Cardinal Anatomical Featuresof Infant’s Larynx 1- Higher Larynx Acute angulationbetween plane of tongue & plane of glottis makes exposure difficult ►straight blade ►exaggerated by mandibularhypoplasia (Pierre Robin syndrome).

  3. 2- Relatively Larger Tongue: Obstructs airway Obligate nasal breathers Difficult to manipulate & stabilize with laryngoscopic blades

  4. 3- Anteriorly Angulated Vocal Cords: The anterior attachment of vocal cords are lower than posterior attachment ►difficulty in nasal intubations where “blindly” placed ETT lodges in the anterior commissure rather than in the trachea.

  5. 4- Differently Shaped Epiglottis Infant epiglottis ohmega (Ώ) shaped and angled away from axis of trachea More difficult to lift an infant’s epiglottis with laryngoscopic blade

  6. 5- Funnel shaped larynx Narrowest part of infant’s larynx is the cricoid cartilage: Tight fitting ETT may cause edema. Uncuffed ETT preferred for patients < 8 years old The only complete ring

  7. Respiratory PhysiologyObligate nasal breathers • Immaturity of coordination between respiratory efforts and oropharyngeal motor/sensory input. • During quiet respiration, the tongue rests against the roof of the mouth.

  8. Respiratory PhysiologyRespiratory Parameters • High metabolic rate (5-8 ml/kg/min) • Tidal volume (6-7 ml/kg/min) • High respiratory rate (40-60 breaths/min) • High alveolar ventilation (130 ml/kg/min) • Lung compliance is less while chest wall compliance is more than those in adults {reduced FRC and atelectasis} ►PEEP.

  9. Respiratory PhysiologyTracheal and Bronchial Function • Infant's larynx, trachea, and bronchi are highly compliant and hence more subject to distention and compression forces • The intrathoracic trachea is subject to stresses that are different from those in the extrathoracic portion

  10. Respiratory PhysiologyDynamic Airway Obstruction Normal inspiratory stretch/collapse (crying) Dynamic collapse at inlet Bronchiolitis/asthma

  11. Respiratory PhysiologyWork of Breathing • The work of breathing is needed to overcome the chest wall compliance and the resistance of the airways. • The WOB per kilogram is similar to adults. • The nasal passages account for 25% of the total resistance to airflow in a neonate, compared with 60% in an adult. In infants, most resistance to airflow occurs in the bronchial and small airways ► respiratory failure with bronchiolitis. • Long, small ETT, obstructed ETT, narrowed airway ► increased WOB ► increased oxygen consumption ► increases oxygen demand.

  12. Change in work of breathing after placement of an appropriate endotracheal tube in extremely low birth weight infants (<1000 g), premature infants (1500 g), full-term infants, children, and adults

  13. Respiratory Physiology Effect of Edema on WOB

  14. Respiratory PhysiologyType I Muscle Fibers Unable to sustain increased WOB for long periods

  15. Evaluation of the Upper Airway (History) • URTI • Snoring (adenoidal hypertrophy, obstructive sleep apnea) • Croupy cough (subglottic stenosis, TEF repair, F.B.aspiration) • Inspiratory stridor (subglottic stenosis or web, laryngomalacia, macroglossia, extrathoracic F.B. or extrathoracic tracheal compression) • Hoarse voice (laryngitis, vocal cord palsy, papillomatosis, granuloma) • Asthma • Repeated pneumonias • Previous anesthetic problem

  16. Evaluation of the Upper Airway (Physical Examination) • Facial expression • Nasal flaring • Mouth breathing • Color of mucous membranes • Retractions (suprasternal, intercostal, subcostal) • Respiratory rate • Voice change • Mouth opening • Size of mouth • Size of tongue and its relationship to other pharyngeal structures (Mallampati)?

  17. Loose or missing teeth. • Size and configuration of palate. • Size and configuration of mandible (side view). • Location of larynx in relation to the mandible. • Presence of inspiratory stridor :epiglottitis, croup, extrathoracic foreign body. • Both inspiratory and expiratory stridor: aspirated foreign body, vascular ring, or large esophageal foreign body. • Prolonged expiration: lower airway disease? • Baseline oxygen saturation in room air.

  18. Bilateral microtia (ear deformity easily notable) is associated with mandibular hypoplasia & difficulty in visualizing the laryngeal inlet (42%) & with unilateral microtia (2.5%). • Are there congenital anomalies that may fit a recognizable syndrome? The finding of one anomaly mandates a search for others.

  19. Evaluation of the Upper Airway (Diagnostic Testing) • X-ray, MRI and CT. Radiologic airway examination in a child with a compromised airway must be undertaken only when there is no immediate threat to the child's safety and only in the presence of skilled and appropriately equipped personnel able to manage the airway. • Endoscopic evaluation (flexible fiberoptic endoscopy) • Arterial blood gas analysis (chronic airway obstruction with respiratory acidosis)

  20. Causes of Difficult AirwayCongenital AnomaliesTumorsInfectionMusculoskeletal Problems

  21. Encephalocele Hallermann-Streiff S. Pierre Robin S. Bilateral Cleft Palate Achondroplasia Down S.

  22. Crouzon S. Seckel S. Treacher Collins S. Goldenhar S. Apert S. Nager S.

  23. Mucopolysaccaridosis Type IH (Hurler) Type 1 H/S (Hurler-Scheie) Type II Hunter Type III (Sanfilippo)

  24. Tumors • Cystic hygroma • Hemangioma of tongue, pharynx • Teratoma • Infection • Retropharyngeal abscess • Epiglottitis • Laryngotracheobronchitis • (subglottic croup) • Ludwig’s angina • Adenotonsillitis, abscess, hypertrophy ( obstructive sleep apnea) • Scleroderma • Laryngeal web

  25. Musculoskeletal Problems • Ankylosis of jaw, cervical spine • Unstable or dislocated cervical vertebrae • Wired jaw • Cervical cord tumor • Halo traction apparatus • Facial trauma, fractures, laceration, burns

  26. Techniques to Open the AirwayHead tilt- Chin lift - Jaw Thrust – Oropharyngeal Airway

  27. Techniques to open the Airway Nasopharyngeal Airway Size Hazards: long, bleeding 30%, intracranial placement

  28. Aligning of the Upper Airway Axes ( More than 6 Years Old) Three-axes theory?

  29. Ventilation Techniques Multi-handed Mask Ventilation

  30. Tracheal Intubation Laryngoscopic Blade Sizes

  31. Tracheal Tube Sizes Insufflation Pressure ?Muscle Relaxants?

  32. Micro-cuff ETT • More anatomical fit • Sealing at low pressures • More distal position • Greater permeability for nitrous oxide • For neonates ≤3 kg and infants ≤1 year, ID 3.0-mm • For children 1 to 2 years of age, ID 3.5-mm • For children ≥2 years, ID (mm) = age/4 + 3.5 • Post-intubation croup was 0.4% (2/500 children)

  33. LMA: Reusable Classic, Disposable Unique, ProSeal Silicone Softer, deeper mask bowl, bite block, improves stability PVC Silicone

  34. LMA sizes

  35. Special Techniques for IntubationRigid Laryngoscopy The retromolar, paraglossal, or lateral approach to rigid laryngoscopy utilizing a straight blade.

  36. Optimal External Laryngeal Manipulation (OELM) OELM is particularly helpful for infants & children with immobile or shortened necks. Either by an assistant or the laryngoscopist. Intubation Guides

  37. Lighted StyletLight Wand

  38. Glidescope Video Laryngoscope

  39. Intubation through LMA (Blind)

  40. Fibreoptic Intubation through LMA

  41. Fibreoptic Assisted Intubation

  42. Percutaneous Cricothyrotomy

  43. Percutaneous needle cricothyrotomy provides only a mean for oxygen insufflation and does not reliably provide adequate ventilation. • If glottic or subglottic pathology is not suspected, LMA placement to establish ventilation may be appropriately attempted first.

  44. Retrograde Intubation

  45. Awake approach? • Sedation? • General anesthesia (inhalation/IV)? “Assisted spontaneous ventilation during inhaled anesthesia is the preferred technique when abnormal airway anatomy is present”.

  46. Rules “To avoid trouble one must be prepared for trouble” “Have an IV access & experienced assistant” “Do what you masters” “Have definitive plan A, but have plan B & C”

  47. Rules “Use your common sense” “ Do not continue to do the same thing and expect different results’’ “Easier comes first” “Each difficult intubation is a different”

  48. Difficult Airway Cart Oropharyngeal/nasopharyngeal airways Laryngosopic blades TT Stylets LMA Fiberoptic laryngoscope PC cricothyrotomy kit Jet ventilation eq. TT exchangers Exhaled CO2 detectors Experienced assistance IV access

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