Pediatric Airway Management

Dr. Shapiro I., PICU

Dec 2003

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EarlyEarly

DefibrillationDefibrillation

Adult Chain of Survival

CPRCPR ALSALSEMSEMS

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Pediatric Chain of Survival

PreventionPrevention ALSALSCPRCPR EMSEMS

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Out-of-Hospital Cardiac Arrest

�SIDS

�Trauma

�Submersion

� Poisoning

�Choking

�Severe Asthma

� Pneumonia

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In-Hospital Cardiac Arrest

�Sepsis

�Respiratory Failure

�Drug Toxicity

�Metabolic Disorder

�Arrhythmias

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PediatricCardiorespiratory Arrests

PediatricCardiorespiratory Arrests

Respiratory

Shock

Cardiac

Respiratory

Shock

Cardiac

10%10%

80%

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Hypoxia and Hypercarbia

Bradycardia

PediatricCardiorespiratory Arrests

PediatricCardiorespiratory Arrests

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Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479

Arrive in ER in Arrive in ER in cardiac arrestcardiac arrest

(N = 80)(N = 80)

Admit PICU(N=43) 54 %

Died in ER(N=37) 46%

Mod Deficit(N=3)

PVS at 12 mos(N=2)

Dead at 12 mos(N=1)

Died in ICU(N=37) 46%

Outcome of cardiac arrest in children

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Survival from Respiratory Arrest

Respiratory Arrest Alone – more than 50% neurologically intactsurvival rate

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Pediatric Chain of Survival

PreventionPrevention ALSALSCPRCPR EMSEMS

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To Simplifythe Message…

EarlyEarly

DefibrillationDefibrillation

With exceptions…

(submersion, trauma, drug overdose)

With exceptions…

(sudden collapse, cardiac history)

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PREVENTION

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Respiratory DistressRespiratory Failure

andRespiratory Arrest

BLS

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Evaluation of Respiratory Performance

�Respiratory Rate and Regularity

� Level of Consciousness

�Color of the Skin and Mucous Membranes

�Respiratory Mechanics

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Respiratory Mechanics

�Head Bobbing

�Nasal Flaring

�Retractions

�Grunting

�Stridor

�Wheezing or Prolonged Exhalation

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Upper Airway Obstruction

turbulence

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Lower Airway Obstruction

turbulence & wheezing

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Anatomy

Children are very different than adults !!!

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Anatomy :

AirwayNoseTongue

Epiglottis Vocal Cords

Larynx

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Anatomy: Larynx

Narrowest point = cricoid cartilage

INFANTADULT

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Physiology

�Tongue - Posterior Displacement

�Tongue – Difficult to Control

�Epiglottis – Difficult to Control

�Vocal Cords – Difficult Intubation

�Tube size relative to Cricoid Diameter

�Small Airway Edema causes High Resistance

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Effect Of Edema

PoiseuillePoiseuille’’ s laws law

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Basic Life Support

A+B

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Two Steps Before…

1. Ensure the Safety of Rescuer and Victim( the scene, gloves, barrier devices)

“Partial” CPR: Is Something Better than Nothing?

2. Stimulate and Check Responsiveness

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Airway

Head Tilt-Chin Lift Jaw Thrust

+ Tongue-Jaw Lift Maneuver (FBAO)

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BreathingCheck Breathing

Look Listen Feel

Recovery Position

Rescue Breathing

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Ventilation withOxygen

� Mouth-to-Mouth ventilation provides only 17% O2

� Indicated to all seriously ill or injured patients even if pCO2 is high

� If Possible – humidify Oxygen

� Use of reduced FiO2 is uncommon

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Devices to Monitor Respiratory Function

�Pulse Oxymetry

�End-Tidal CO2

�Arterial Blood Gas Analysis

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Oxygen Delivery Systems

�Oxygen Mask

�Face Tent

�Oxygen Hood

�Oxygen Tent

�Nasal Canula

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Oropharyngeal Airway

SIZE PROPER POSITION

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Nasopharyngeal Airway

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Nasopharyngeal Airway

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Bag-Mask Ventilation

Proper area for mask application

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Bag-Mask Ventilation

Sellick Maneuver

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Laryngeal Mask

Contraindicated if gag-reflex is intact

Higher success rate

Does NOT protect from aspiration

Difficult to maintain during transport

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Intubation

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Intubation: Indications

�Failure to oxygenate

�Failure to remove CO2

�Increased WOB

�Neuromuscular weakness

�CNS failure

�Cardiovascular failure

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Tracheal Tube

Children > 2 years:ETT size: (Age+16)/4ETT depth (lip): ETTsize x 3

Children > 2 years:Children > 2 years:ETT size: ETT size: (Age+16)/4(Age+16)/4ETT depth (lip): ETT depth (lip): ETTsize x 3ETTsize x 3

Age kg ETT Length

Newborn 3.5 3.5 93 mos 6.0 3.5 101 yr 10 4.0 112 yrs 12 4.5 12

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Better in younger children with a floppy epiglottis

Straight

Laryngoscope Blades

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Laryngoscope Blades

Better in older children who have a stiff epiglottis

Curved

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Intubation Technique

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Confirmation of ETT Placement

�NO single technique is 100% reliable

�Clinical Confirmation

�Chest X-ray

�CO2 Detection

�Esophageal Detector Devices

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Clinical Confirmation

�Chest rise

�Water vapor seen inside tube

�Breath sounds - lung

�Breath sounds – epigastrium

�O2 Saturation

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Acute Deterioration after Intubation

Acute Deterioration after Intubation

D.O.P.ED.O.P.E:: DDisplacementisplacement

OObstructionbstruction

PPneumothoraxneumothorax

EEquipment failurequipment failure

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Inadequate Improvement after Intubation

� Inadequate Tidal Volume

�Excessive Leak Around The Tube

�Air Trapping and Impaired Cardiac Output

� Leak or Disconnection in Ventilator System

� Inadequate PEEP

� Inadequate O2 Flow from Gas Source

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Percutaneous CricothyrotomyPercutaneous

CricothyrotomyComplete UA Obstruction:

�FBAO

�Severe Orofacial Injuries

�Upper Airway Infections

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See You at Next Week’s Workshop

Happy Khanukka