Robin Foster MD FAAP FACEP Division Chief Pediatric Emergency Medicine Children s Hospital of Richmond at Virginia Commonwealth University Health

Transcription

1 Robin Foster MD FAAP FACEP Division Chief Pediatric Emergency Medicine Children s Hospital of Richmond at Virginia Commonwealth University Health

2 How hard can it be? 260 Pediatric Emergency Airway Encounters by Air Transport Personnel Tollefsen et al Dept EM Brigham Harvard PEC Sept intubations in 3 year period were pediatric intubations 88 (33.8%) medical 172 (66.2%) trauma #1 head trauma n=64 #2 seizures n=26

3 How hard can it be? 260 Pediatric Intubations Mean age 7 years 98.8% orotracheal intubations with RSI 1 st attempt 78.6% n=202 Ultimate rate 95.7% n=246 </= 2 attempts 95.9% n=236 Medical and Surgical diagnoses had equal success rates All age groups had equal success rates 0-2 years 8-14 years 3-7 years

4 How hard can it be? 260 Pediatric Intubations 11 patients not successfully intubated 7 LMA placed 2 Combitube 2 Rescue Cricothyrotomy Needle Cricothyrotomy in a 2 yo Surgical Cricothyrotomy in a 14 yo No mortality because of a failed endotracheal intubation 3 patients 1.1% were managed initially and successfully with EGD

5 Supraglo5c Airways Any airway device that sits outside the larynx and forms a seal around it Original device: esophageal obturator airway (EOA) 1973 Complications included: Incorrect Placement Esophageal injury No pediatric sizes

6 Subglo5c Airways Combitube is an esophageal tracheal double lumen double cuffed airway developed in the early 1980s Ventilation is traditionally provided thru the proximal lumen which opens at the larynx while inflating the distal cuff to obstruct the esophagus Two sizes: foot patient 41 >5 foot patient No pediatric sizes

7 Pediatric Supraglo5c Airways King Airway System (LTS- D LT- D LT) is a curved tube with ventilation apertures located between two balloons with one valve to inflate both the esophageal and the oral pharynx balloon. Introduced US 2003 Pediatric sizes: inches height pt inches height pt Average 2 yo 35 inches

8 Pediatric Supraglo5c Airways King airways are the most common prehospital supraglottic airway in EMS Cuff volumes ml ml Pediatric sizes for King LT- D only: no gastric outlet

9 Pediatric Supraglo5c Airways The patent for the first laryngeal mask airway (LMA) was issued to a British anesthesiologist Dr Archie Brain in 1982 Since then the LMA has been used over 300 millions times in anesthesia and emergency airway management Comprised of an airway tube and an elliptical mask with an inflatable or self sealing cuff Term LMA has been replaced by the term SGA because of number of new devices

10 Pediatric Supraglo5c Airways An update on newer pediatric supraglottic airways with recommendations Jagannatman et al Ped Anesth April 2015 Old SGAs LMA classic 1987 and LMA Unique 1997 LMA Proseal 2000/ pediatric sizes 2004 New SGAs Air Q i- gel LMA Supreme Ambu aura- i

11 Pediatric Supraglo5c Airways LMA Classic- 1 st generation LMA Proseal- 2 nd generation

12 Pediatric Supraglo5c Airways Air- Q- 2 nd generation i- gel- 2 nd generation

13 Inser;on of LMA type SGA

14 Pediatric Supraglo5c Airways Device Cost $ Smallest size Generation Gastric out LMA Classic <5kg kg kg kg 1st 91% Ease 1 st attempt LMA Unique <5kg 1st 89% LMA Proseal <5kg 2nd 94% Air- Q <4kg 1 st (or 2 nd ) 99% Ambu- aura <5kg 1 st (or 2 nd ) 93% LMA Supreme <5kg 2nd 97% i gel <5kg 2nd 91%

15 Pediatric Supraglo5c Airways Device Leak pressure Cm H2O Conduit for intubation Concerns LMA Classic Narrow/long Gastric insufflation(gi) LMA Unique Narrow/long Low pressure GI LMA Proseal Narrow/long Requires exchange for TI Air Q Wide/short Ambu- aura Wide/short 1.0 and 1.5 φ TI cuffed tubes LMA Supreme Narrow/long Requires exchange for TI i gel Wide/short Dislodges

16 Applica;ons of SGA data If a child has received BMV prior to placement of the SGA then gastric decompression is important either prior to placement of SGA or use SGA with a gastric outlet If patient requires ongoing positive pressure ventilation or has intrinsic lung disease then gastric outlet and high leak pressures relevant to ensure adequate ventilation/ oxygenation If patient ultimately requires definitive airway placement then the shorter wider tubes facilitate conduit tracheal intubation without using exchange catheters/guide wires

17 Intuba;on of the Pediatric Pa;ent New indirect laryngoscopes that do not rely on the alignment of the oral- pharyngeal- tracheal axes Potential to benefit pediatric patient population greatly because of the relatively small size of the pediatric airway and the difficulty in obtaining direct visualization of the airway past the small oral opening Commonly used current products that have pediatric blades within the last ten years include: Glidescope CMAC Truview EVO2 PCD

18 Glidescopes AVL reusable 4 size blades GVL 2,3,4,5 Delay in high level disinfection process AVL disposable Two size video batons 1-2 neonates/small children 3-4 children /adults 6 size blades Immediately available again to be used

19 Glidescope Video Batons and Blades are weight based Video baton Blade size Weight parameter (kg) < adult 4 40 and up

20 The Literature on Glidescopes Kim et al 2008 British Journal Anesth compared the glidescope with direct laryngoscopy in 203 children >50% of the time the glidescope provided a better glottic view but a longer time to intubation 36 seconds with a glidescope 23.8 seconds with direct laryngoscopy Lee et al 2013 found that a Glidescope blade size that was one smaller than the recommended blade based on weight improved the view of the glottis compared to the recommended GL blade or direct laryngoscopy Neutral position and jaw thrust manuevers instead of traditional cricoid pressure improved view as well

21 The Literature on Glidescopes Validation of the Glidescope video laryngoscope in the pediatric patient Redel et al Ped Anesth July patients < 10 years old ASA I- III airways Randomized by airway class to glidescope vs Macintosh intubation Anesthesiologists performed the intubations No significant difference in trauma based on bleeding in the airway comparing glidescope to Macintosh

22 CMAC One handle size Reusable Blade sizes Miller 0,1 Mac 2,3,4 Disposable Blades Miller sizes not available

23 The Literature on CMAC Studies have looked at infants <10kg (Mutlak et al 2014) as well as older children (Singh et al 2015) in terms of success of intubation and time Equal success comparing CMAC with Macintosh Better visualization of the glottis/cords with CMAC Slightly longer times to intubate using indirect versus direct larnygoscopy 28 sec vs 26 sec Intubations performed by anesthesiologists who had experience with equipment Theory is that this difference in time to intubation will persist because of the parallax of placing the tube thru the cords based on an indirect image that requires eye hand coordination

24 TruView EVO2 Angled blade Narrow distal portion Integrated oxygen jet cleaning system 2-5l/ min to prevent fogging and provide apneic oxygenation Infant blade: 1-10kg

25 The Literature on TruView Infant (Mutlak et al 2014) and children (Singh et al 2015) comparative studies demonstrate the best visualization of the cords with TruView compared to direct or other indirect devices Much longer time to intubate 52 sec vs 28 sec with CMAC and 26 sec with direct laryngoscopy No difference in oxygenation but presumptively because of the ability to deliver oxygen during the process TruView had much lower user satisfaction scores

26 Cannot intubate Cannot ven;late neonate or infant Surgical cricothyrotomy is not indicated because of the small dimensions of the cricothyroid membrane Cricoid cartilage is an important circumferential supportive structure for the trachea to maintain patency Surgical tracheostomy is the ultimate option but difficult procedure Needle cricothyrotomy or needle puncture transtracheal is immediate solution

27 Needle Cricothyrotomy Effective ventilation is problematic High pressure gas flow is required to overcome the small diameter resistance No data on using transtracheal jet ventilation on infants and small children Animal data Wong et al Peds Anesthesia 2014 Jet ventilator or a commercial oxygen modulator with noncompliant tubing and a luerlock connected to high flow oxygen both achieve improved oxygenation over the same time frame and sustained it for 15 minutes allowing time to set up for surgical trach

28 Nitric oxide in Pediatric Acute Respiratory Distress Syndrome Bronicki et al Multicenter Randomized Trial Journal of Peds Feb 2015 Hypothesis: Inhaled nitric oxide (ino) would lead to improved oxygenation and decreased duration of mechanical ventilation in pediatric acute RDS 55 children in 9 centers randomized to ino or placebo Survival rate between the two groups at 28 days 92% 22/24 in ino and 72% 21/29 in placebo (p=0.07) Significant reduced duration of mechanical ventilation Significant increased rate of ECMO free survival

29 Pediatric Airway Cases:#1 2 yo male who refuses to eat and is febrile to 102 Pt is anxious and scared appearing Mouth open

30 Epiglo5;s Etiologic agents: Staph aureus Group A streptococcus Candidal supraglottitis in HIV Pediatric ENT or anesthesia Ceftriaxone and clindamycin

31 Pediatric Airway Cases: #2 18 mo old female with runny nose for two days and now with audible stridor and retractions of intercostals with nasal flaring at rest

32 Croup Parainfluenza virus type 1 Xrays rarely needed unless child excessively febrile or toxic appearing AP view with steeple or pencil sign Lateral view haziness of the subglottic region and distension of hypopharynx more sensitive and specific

33 Pediatric Airway Cases: #3 5 yo male who has fever chills malaise and decreased po Exam with left sided cervical adenopathy and poor visualization of the posterior pharynx

34 Retropharyngeal Abscess Prevertebral soft tissue swelling > the width of the vertebrae Try to take film in retroflexed position instead of straight upright to avoid false positives 6mo- 6years suppurative changes of retropharyngeal nodes or trauma Group A beta hemolytic strep, nonhemolytic strep, Staph aureus or bacteriodes CT/OR drainage/ clindamycin and zosyn or unasyn

35 Pediatric Airway Cases:#4 18 mo old female who presents with cough, high fever and inspiratory stridor Case #2 sent home two nights ago with diagnosis of croup after improving s/p decadron and epinephrine Inc WOB and sats 90%

36 Bacterial Trachei;s Persistent subglottic narrowing Post croup presents much like epiglottitis Mucosal damage and impairment of local immune mechanisms secondary to viral infection Staph, strep pneum or pyogenes, H influenza and Moraxella

37 Bacterial Trachei;s Intubation with anesthesia/pediatric ENT if available Ceftriaxone and Clindamycin

38 Pediatric Airway Cases: #5 2 yo male who was in high chair and acutely developed respiratory distress with wheezing and marked increased work of breathing and hypoxia sats 70s Pt has a history of asthma but no response to bronchodilators

39 Aspira;on of beef macaroni and cheese Expiratory film shows hyperinflation of left chest because of left main stem obstruction Intubate right main stem if traditional tube placement fails and oxygenate and ventilate judiciously secondary to risk of ptx IV steroids Rigid bronchoscopy