Pediatric Airway- You Swallowed What?

Transcription

1 Pediatric Airway- You Swallowed What? Staci Kothbauer, CRNA, MS, APNP University of Wisconsin Hospital American Family Children s Hospital Madison, WI 1

2 Objectives * Understand basic pediatric airway anatomy and how it differs from adults * Identify common syndromes associated with a pediatric difficult airway * Describe techniques to manage a difficult airway * Identify risk factors for airway complications during a general anesthetic in the pediatric patient * Identify common airway emergencies that may present management challenges Pediatric airway anatomy * Tongue- large in proportion to oral cavity * Position of larynx- higher in neck (C3-4) peds vs (C4-5) in adults Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 2

3 Pediatric airway anatomy * Epiglottis- large, floppy, and angled away from axis of trachea Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric airway anatomy * Subglottis- narrowest portion of larynx is cricoid cartilage Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 3

4 Pediatric airway anatomy * Vocal Cords- lower attachment anteriorly * Axis of VC is perpendicular to the trachea Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric airway * Cuffed vs Uncuffed ETT * Cuffed ETT- (age/4) +3 * Uncuffed ETT- (age/4) +4 * Distance- (age/2) +12 * Leak at cm H20 * May want to consider uncuffed in infants with anticipated prolonged intubation Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 4

5 Microcuff ETT Pediatric airway * Complications of intubation * Post- intubation croup * ETT to large * Surgery > 1 hour * Repeated attempts * Traumatic intubation * Age 1-4 * Position other than supine * Change in position during procedure * Coughing on ETT * Previous history of croup Wheeler, M, Cote, C, J, & Todres, D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 5

6 Pediatric syndromes * Pierre Robin * Mandibular hypoplasia * Direct visualization may be difficult, if not impossible Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric syndromes * Achondroplasia * Difficult intubation * Midfacial hypoplasia * Small nasal passages and mouth * Megacephaly Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 6

7 Pediatric syndromes * Marfan syndrome * Difficult intubation * Narrow palate or high arched palate * Scoliosis or kyphosis * Cardiac and pulmonary disease * Dissecting aortic aneurysm Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric Syndromes * Rheumatoid Arthritis * Limited TMJ mobility * Hypoplasic mandible * Cricoarytenoid arthritis with narrow larynx * Cervical spine subluxation, rigid cervical spine Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 7

8 Pediatric syndromes * Scleroderma * Extensive scarring of mouth, face and body * Difficult intubation * Decreased pulmonary compliance * Chronic steroid use Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric syndromes- Treacher- Collins 8

9 Pediatric syndromes * Trisomy 21 (Down s syndrome) * Small mouth * Small mandible * Large, protruding tongue * Cervical spine subluxation * Consider ½- 1 size smaller ETT Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Pediatric syndromes * Turner syndrome * Narrow maxilla * Small mandible * Short neck * Difficult intubation * Associated cardiac disease * Hypertension Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 9

10 Management of the Pediatric Difficult Airway * Awake vs Asleep * Asleep * Spontaneously breathing * Helpful in locating glottis * Avoid neuromuscular blockade * Sedation- if tolerated * Midazolam (0.05 mg/kg IV) and fentanyl (0.5-1 mcg/kg IV) * Ketamine ( mg/kg IV) every 2 minutes * Psychomimetic emergence reactions less in children Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Anesthetizing the airway * Nebulized lidocaine * Topical spray or jellies * Translaryngeal lidocaine * spray as you go with lidocaine * Superior laryngeal nerve block * Use caution not to deliver toxic lidocaine doses * 5 mg/kg or 7 mg/kg with epinephrine Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 10

11 Unexpected Difficult Airway * Biggest difference from adult * metabolic rate * FRC * Time from zero 02sat from inspired concentration of 90% to neurological injury * Adults- 10 minutes * Children- 4 minutes!!!! Wheeler M, Cote CJ, & Todres D. (2009). Pediatric Airway. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp. 263). Philadelphia: Saunders Company. Who is at risk for respiratory adverse events? * Laryngospasm * 14% in <6 year olds to 3.6% in >6 year olds (1) * Higher ASA score * Type of airway device used (1-4) * Upper respiratory infection (URI) (5) (1) Murat I, Constant I, Maudhuy H. Perioperative anesthetic morbidity in children: a database of 24, 165 anesthetics over a 30- month period. Pediatric Anesthesia 2004; 14: (2) Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anesthetic complications in children with respiratory tract infections. Pediatric Anesthesia 2001; (3) Tait AR, Malviya S, Voepel- Lewis T et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001; 95: (4) Rachel Homer J, Elwood T, Peterson D, Rampersad S et al. Risk factors for adverse events in children with colds emerging from anesthesia: a logistic regression. Pediatric Anesthesia 2007; 17: (5) Flick R, Wilder R, Pieper S et al. Risk factors for laryngospasm in children during general anesthesia. Pediatric Anesthesia 2008; 18:

12 Upper Respiratory Infections * Bordet et al. in Pediatric Anesthesia (2002) (1) * <6 years * Recent RI * Use of LMA * Flick et al. in Pediatric Anesthesia (2008) (2) * 130 children with laryngospasm under GA * Significant association between laryngospasm and current URI or airway anomaly * LMA + URI=strong association (1) Bordet F, Allaouchiche B, Lansiaux S et al. Risk factors for airway complications during general anesthesia in pediatric patients. Pediatric Anesthesia 2002; 12: (2) Flick R, Wilder R, Pieper S et al. Risk factors for laryngospasm in children during general anesthesia. Pediatric Anesthesia 2008; 18: When to Cancel? * Croup, bronchitis, bronchiolitis, or pneumonia * Within 4-6 weeks * Current or new URI * Dependent on procedure * Fever * Wheezing * Wet cough * Patient history- asthma Ghazal EA, Mason LJ, & Cote CJ. (2009). Preoperative Evaluation, Premedication, and Induction of Anesthesia. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp.60-62). Philadelphia: Saunders Company. 12

13 When to Cancel? * How long to postpone? * Ideally 7 weeks.not practical * Postpone 2 weeks * Bottom line- proceed with caution if asymptomatic Ghazal EA. Mason LJ, & Cote CJ. (2009). Preoperative Evaluation Premedication, and Induction of Anesthesia. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp.60-62). Philadelphia: Saunders Company. Orliaguet GA, Olivier G, Savoidelli GL, et al. Case Scenario: Perianesthetic Management of Laryngospasm in Children. Anesthesiology 2012; 116: Laryngospasm * Chin lift * Jaw thrust * Positive pressure * Propofol * Succinylcholine (0.5 mg/kg IV) or (3-4 mg/kg IM) (1) * Rocuronium (4-5 mg/kg IM) (2) * Treatment depends on severity of laryngospasm (1) Orliaguet GA, Olivier G, Savoidelli GL, et al. Case Scenario: Perianesthetic Management of Laryngospasm in Children. Anesthesiology 2012; 116: (2) American Academy of Pediatrics, Committee on Drugs. Drugs for Pediatric Emergencies. Pediatrics 1998; 101: e13. 13

14 Airway Emergencies * Epiglottitis, foreign body, bleeding tonsil * AIRWAY TAKES PRIORITY OVER FULL STOMACH * Keep spontaneously breathing * Laryngoscopy under deep volatile agent * ***KEEP CHILD CALM*** * Clear communication with ENT surgeon and OR staff PRIOR to induction Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Airway Emergencies * IV after induction * Parents into OR???? * Induce in sitting position * IV ml/kg of LR rapidly * Early administration of atropine (10 mcg/kg IV) or glycopyrrolate (10 mcg/kg IV) Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 14

15 Upper Airway Obstruction- inspiratory stridor, retractions, tachypnea * Epiglottitis * Keep child calm * Inhalation induction in sitting position * IV, rapid rehydration, atropine (10 mcg/kg) * Deep intubation * ETT ½ size smaller * Unable to intubate trach * Post- op- PICU, hrs. Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Foreign Body Aspiration * 5 th leading cause of death in <1 year olds * May present with wheezing, cough, and unilateral breath sounds * Emergency treatment if symptomatic OR * If stable, radiographic exam * DO NOT INDUCE WITHOUT ENT SURGEON! Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 15

16 What is the foreign body? LEGO! 16

17 Tonsil Bleed * Occurs within 6 hours, or 5 to 10 days post- op * Considered full stomach * Potential loss of airway * Hemodynamic compromise * ***Replace fluid, if possible, and draw Hgb/Hct Hannallah RS, Brown KA, & Verghese ST. (2009). Otorhinolaryngologic Procedures. In Cote, et al (4 th Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Tonsil Bleed * IV access prior to induction * Pretreat with atropine (10 mcg/kg IV) or glycopyrrolate (10 mcg/kg IV) * Induce with ketamine (1-2 mg/kg IV) or etomidate (0.3 mg/kg IV), and succinylcholine (1.5-2 mg/kg IV) * RSI * Difficulty visualizing VC- press on stomach * Limit opioids * OG tube prior to extubation Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3 rd Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 17

18 Asthma in Emergency cases * Goals: oxygenation, reduce airway obstruction, prevent complications * RSI if full stomach- avoid light intubation * Premed prior to induction * Opioids, IV lidocaine * Glycopyrrolate or atropine * Increase expiratory time to prevent air trapping * Accept somewhat elevated PaC02 * Limit peak inspiratory pressure to cm H2o Everett LL, Fuzaylov G, & Todres D. (2009). Pediatric Emergencies. In Cote, et al (4th Ed.), A Practice of Anesthesia for Infants and Children (pp.775- ). Philadelphia: Saunders Company. Bronchospasm * Treatment * Bronchodilator- nebulized or metered- dose inhaler * Albuterol * Beta- adrenergic agents * Epinephrine 1:1000 (0.01 mg/kg) SQ every 15 min x3 (max 0.3 ml) * Terbutaline ml/kg (max 0.25 ml) SQ every 30 min x2 or 0.1 mcg/kg/min, titrate to effect Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3 rd Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. 18

19 Asthma * Corticosteroids * Hydrocortisone 7 mg/kg IV immediately and 7 mg/kg/24hr, divided in 6 doses * Methylprednisolone 2 mg/kg IV immediately and 2 mg/kg/24hr, divided in 6 doses * Dexamethasone 0.3 mg/kg IV immediately and 0.3 mg/kg/24hr, divided in 6 doses Campo S, Denman W, & Todres D. (2001). Pediatric Emergencies. In Cote, et al (3 rd Ed.), A Practice of Anesthesia for Infants and Children (pp ). Philadelphia: Saunders Company. Conclusions * Pediatric airway anatomy is different from that of an adult airway * Be alert to children with syndromes and the potential for a difficult airway * Keep the child spontaneously breathing when a difficult airway is suspected * Proceed with caution with recent URI * Keep child calm during emergency airway situations * Avoid light anesthesia with asthmatics 19

20 Questions?? 20