Pediatrics

Matthew Musick, MD

Fellows Boot Camp 2013

Airway Adjuncts, Bag Mask

Ventilation, and Laryngeal

Mask Airways

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Pediatrics

Objectives

•Be able to choose proper size oral/nasal airway,

facemask (for BMV), and LMA according to

anatomic landmarks and patient age/size

•Learn complications from various airway

maneuvers

‐5 complications related to use of airway adjuncts

‐3 complications related to BMV

‐3 complications related to LMAs

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Pediatrics

Pediatric vs Adult Airway

Infant Adult

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Pediatrics

Positioning (“sniffing”)

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Pediatrics

Positioning - Infant

R

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Pediatrics

Positioning - Comparison

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Pediatrics

Obstruction

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Pediatrics

Options – Chin lift

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Pediatrics

Options – Jaw Thrust

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Pediatrics

Options – Oral Airway

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Pediatrics

Oral Airway

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Pediatrics

Oral Airway – Too Small

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Pediatrics

Oral Airway – Too Large

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Pediatrics

Insertion Technique

•First open mouth (can use cross finger scissor

technique)

•Option # 1 – push tongue down w/ tongue

depressor and insert “straight in”

•Option # 2 – insert “upside down” and then

rotate 180 degrees as oral airway is being

advanced to back of oropharynx

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Pediatrics

Oral Airway Complications

•Yak*$%! (ie the gag reflex)

•Obstruction (not really your desired effect)

•Laryngospasm

•Tooth/mouth injury

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Pediatrics

Nasopharyngeal Airways

•Same concept of relieving tongue obstruction

•Better tolerated than oral airway if patient semi-

conscious or awake

•Contraindicated with:

‐Significant facial trauma (esp basilar skull fracture)

‐Severe coagulopathy

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Pediatrics

Size Selection

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Pediatrics

Nasopharyngeal Airway Insertion

•Don’t forget the lube!

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Pediatrics

Bag Mask Ventilation

•True life saving technique

•Can oxygenate and ventilate

•Helpful during intubation

‐Can “improve” patient so that intubation is less

strenuous

‐Can “rescue” patient if intubation attempt fails

•May need airway adjunct and two people!

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Pediatrics

Equipment

•Self inflating reservoir bag, unidirectional valve,

standard mask connector, oxygen hook-up

‐Manometer, PEEP valve

•Different size masks

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Pediatrics

Mask Size and Fit

•Extend from bridge of nose to chin (covering

mouth and nose)

•Inflatable rim can help assure seal

•“E-C” hold is preferred technique

‐Thumb and forefinger form C on top of mask

‐Middle/ring fingers on ridge of mandible (chin lift)

‐Pinky behind angle of mandible (jaw thrust)

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Pediatrics

E-C Hold

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Pediatrics

Successful BMV

•Chest rise

•Chest rise

•Chest rise

•Increased O2 sats, auscultation, condensation

in mask

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Pediatrics

Complications of BMV

•Excessive air in stomach

‐Aspiration risk

‐Decreases lung volume/requires higher PIPs

•Corneal abrasions

•Injury to lips/gums and nasal bridge

•Excessive bagging due to user exuberance

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Pediatrics

Laryngeal Mask Airway

•Many uses/indications for our anesthesia

colleagues

•Rescue airway device in PICU

•Supraglottic airway that can be placed “blindly”

but is temporary in nature

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Pediatrics

LMA

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Pediatrics

LMA

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Pediatrics

LMA Notes

•Size selection is based

on weight – look at

package!

•It will “pop up” slightly

after cuff is inflated if

seated correctly

•Don’t forget the lube

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Pediatrics

LMA Insertion

•Few methods…

•Forefinger guiding

technique

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Pediatrics

LMA Insertion

•Rotational method

‐Similar to oral airway rotation

‐“Cuff” is pointed up towards palate

‐After advancing past the tongue, you rotate 180 degrees

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Pediatrics

LMA Insertion

•Just stick it

in

•Works best

for curved

LMA

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Pediatrics

LMA Complications

•Aspiration (although much less than

traditionally feared)

•Gagging and possibly laryngospasm

•Difficult to achieve high peak inspiratory

pressures

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Pediatrics

Questions???