Management of Airway and Breathing

1. Management of Airway and Breathing RHSC Edinburgh

2. Objectives To understand the differences between children and adults To understand that airway and breathing should be considered together To recognise the compromised airway To recognise inadequate breathing To be able to support compromised airway and breathing as required

3. What are the differences between the paediatric and the adult airway?

4. Anatomy Smaller airway Large tongue Floppy epiglottis Funnel shape - cricoid narrowest part of larynx (up to ~ 10yrs) Larynx is anterior and high in the neck Positioning may be affected by relatively large occiput in infants

6. Babies < 6 months are obligate nasal breathers: blocked nose = blocked airway Ventilation is mainly diaphragmatic – if diaphragm movement is impeded tidal volume is reduced (eg full stomach) Trachea & bronchi are smaller – a minimal obstruction makes a big difference to flow

8. Why do children desaturate faster than adults?

10. Supply and demand! Ventilatory reserve is less O2 consumption is higher because metabolic rate is higher 6-8ml/kg/min in children 3-4ml/kg/min in adults

12. Signs of airway compromise See-saw respirations Diaphragm flattens Abdo contents pushed down Abdo rises Chest “sucked in” Paradoxical

13. Signs of airway compromise Stridor Drooling Increased work of breathing Reduced or absent air entry Low / falling SaO2

14. Signs of respiratory compromise Increased work of breathing Increased respiratory rate Nasal flaring Intercostal, subcostal, suprasternal and sternal recession Head-bobbing Prolonged expiration +/- wheeze Grunting

15. Signs of respiratory compromise Poor chest excursion and air entry Cyanosis/low SaO2 Hypoxaemia and or hypercapnia with acidosis on blood gas Tachycardia then bradycardia Reduced conscious level

16. Problem detected – NOW WHAT!?!

17. Back to basics Assess ABC Get help High flow O2 Positioning – sit up if alert/able DO NOT distress the child Treatment for specific problem (eg wheeze)

18. Consider IV Access (likely to be needed) Investigations as appropriate Blood tests Cultures Gases CXR

19. Asthma 9% of children - most common disease of childhood Death rates for all ages – 50% at home 2.1 / 1,000,000 children < 5 years 3.7 / 1,000,000 children 5-14 years 2 / 10,000 of those hospitalized

20. Management of asthma Nebulised Salbutamol & Atrovent Steroids IV Salbutamol IV Aminophylline IV Magnesium sulphate Mechanical ventilation Volatile anaesthetic agents Heliox ECMO

23. Management of asthma Escalation of medical management Consultation with PICU early Protocols Aim is to avoid intubation if at all possible Difficult to ventilate Risk of iatrogenic pneumothorax, pneumomediastinum Mucous plugging and atelectasis Nosocomial infection

24. Into this Intubation may turn this

25. Obtunded with compromised airway or breathing Get help High flow O2 Simple airway manoeuvres Suction (remember nasal suction in infants) Consider adjuncts – OPA, NPA Ventilatory support with bag-valve-mask if required

26. Airway adjuncts Oropharygeal airway (OPA) In infants and young children insert right way up with tongue depressor Nasopharyngeal airway (NPA) Use appropriate sized ETT cut to length (tip of nose to tragus of ear)

27. Bag-valve-mask ventilation Well-fitting face mask Correct head position Neutral for infants “Sniffing” for younger children Fingers on bone One or two person technique Watch chest wall movement Consider OGT/NGT to decompress stomach

28. Does this child need intubation?

29. Indications for intubation Decision to intubate can be difficult Threshold for intubation is lower if patient is to be transferred Aim to optimise condition prior to transfer

30. Indications for intubation Deteriorating airway recession, “see-saw” breathing, stridor Potential airway obstruction eg trauma, burns Respiratory distress Tachypnoea Chest wall recession Hypoxaemia: SaO2 < 94%, or PaO2 < 8 kPa Hypercapnia with acidosis: PaCO2 > 6 or < 3.5 kPa Exhaustion Apnoeas Respiratory arrest

31. Indications for intubation Shock HR > 180 or < 80 (< 5yrs), > 160 or < 60 (> 5yrs) absent peripheral pulses cold peripheries capillary refill > 2 sec systolic blood pressure < 70 + (age in years x 2)    Not responding to fluids > 60mls/kg Requiring inotropes Deteriorating level of consciousness GCS 8 or less Responding to Pain on AVPU Recurrent seizures

32. Intubation should be undertaken by an appropriately skilled person

33. Preparing for intubation Assessment of the patient Assume full stomach – IV induction should be rapid sequence induction (RSI) Equipment Drugs Personnel A plan for failure

34. Assessing the patient History current illness Airway obstruction? Consider gas induction Shock? Induction agents vasodilate – consider drug/dose Head injury? Avoid raised ICP in response to laryngoscopy previous intubation details ?difficult airway eg Pierre Robin Examination head - shape / size mouth - size / opening teeth - size / integrity jaw - size / receding tongue - size neck - mobility / Cx spine injury / swelling / masses

35. Equipment Laryngoscope x 2 and appropriate blades Appropriate size ET tubes Airway adjuncts Suction Stylet & or bougie Magills forceps Monitoring - including ETCO2 if available Scissors and tape KY jelly

37. Drugs Sedating agent If unstable reduce dose or consider Ketamine Muscle relaxant Suxamethonium unless CI for RSI Sedation and opiate infusions for maintenance Emergency drugs Atropine Adrenaline Consider infusion of inotrope if haemodynamically unstable See retrieval website for dose calculations www.paedsretrieval.co.uk

38. Rapid Sequence Induction algorithm Preparation: equipment / drugs / patient / personnel IV access patent, checked monitoring on, working aspirate nasogastric tube suction Pre-oxygenation Administer anaesthetic agent Cricoid pressure Administer suxamethonium Intubation Position check Tracheal tube fixation Position check

39. Failed intubation drill Maintenance of oxygenation is the priority Call for HELP Do not make persistent attempts at intubation Do not give repeated doses of suxamethonium Maintain a patent airway Bag and mask ventilate to maintain oxygenation Continue cricoid pressure unless it is impeding ventilation Left side and head down unless this impedes ventilation

40. Key points for intubation Oxygenation is always the priority Never lose control of the airway “can’t intubate, can’t ventilate” Bag valve mask ventilation is the default position of safety An adequately trained team is required / ask for help Adequate patient assessment and equipment preparation Plan for a failed intubation

41. After the tube is in…. Maintenance infusions Sedative, opiate +/- relaxant Monitor ETCO2 NGT if not already inserted CXR to confirm position If problems, think DOPES D displacement O obstruction P pneumothorax E equipment S stomach

42. Summary Children are not small adults Anatomical and physiological differences make them more at risk of respiratory problems Assessment, O2 and simple supportive measures initially Call for help early If required intubation should be undertaken by appropriately trained personnel Adequate preparation is needed