Case 1: Fast and noisy. The Ins and Outs of the Pediatric Airway. Airway: anatomic differences. Objectives 2/16/2014
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1 Case 1: Fast and noisy The Ins and Outs of the Pediatric Airway Judith Klein, MD, FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Department of Emergency Medicine 8 month old BIB parents for noisy breathing VS: RR 70, O294%, T39 -nasal flaring, grunting, and retractions -crackles throughout Wonder if she ll poop out? Objectives Basic anatomic and physiologic differences between kids and adults airway/breathing Airway BLS: monitors, airway adjuncts, BVM Airway ALS: Direct laryngoscopy in kids Large occiput Airway: anatomic differences Large tongue/tonsils Floppy epiglottis Alternatives to direct laryngoscopy Alternatives to intubation: the LMA The airway disaster: the neck! More cephalad and anterior airway Narrowest at cricoid ring Adult Infant 1
2 Anatomic differences Secretions easily block airway Increased aspiration risk Flexible thoracic cage: retractions/paradoxical breathing Immature respiratory muscles: tire easily Obligate nasal breathers <6 months Conditions that can cause airway problems Genetic/congenital: -trisomy 21, Pierre-Robin Infection -croup, epiglottitis, abscess Rheumatologic -JRA Burns/trauma A/B Physiologic differences High metabolic rate O2 consumption MV=RR x TV high TV limited by thorax size MV more RR dependent RR with respiratory compromise or with increased metabolic demand Physiologic differences Limited respiratory reserve Apnea time to 90% O2 sat after preoxygenation: -6 minutes adult/adolescent -90 seconds if <6 months* *Patel, et al. Can J Anesth
3 Case 2: Let s use the propofol 2 year old with distal radius fracture Propofol for reduction O2 sat to 92%, sonorous respirations What now? Monitors: -Basic: pulse ox, HR, BP - ETco2 key to early detection of hypoventilation (Re-)Positioning: -large occiput -roll under shoulders Suction: -secretions/blood easily obstruct airway -nasal sxn in infants Airway BLS Jaw thrust-->airways adjunct: -NP: nares to tragus -OP: mouth to angle of jaw BVM: -bridge of nose to cleft of chin -2 person technique -lift face to mask: don t push mask onto face Airway BLS Case 3: Code 3 call-14 mo old asthma Paramedic ringdown: 14 mo old severe asthma, declining RR and HR: Doc, should we tube him? *Gausche, et al. JAMA OOH success with intubation: *< 3 yrs old: 56%! *3-8 yrs: 61%! No difference in survival or neuro outcome ETT or BVM 2010 ALS: BVM preferred over intubation if transport time short 3
4 He s circling the toilet bowl.. In ED, pt sleepy, RR 14, O2 90%, minimal air movement Asthma meds? Silastic therapy? Working on the IV... Airway ALS: RSI or TED? (Tie Em RSI!: even in neonate (2x greater success, fewer complications) Down) (? Paralytic choice? -Succinylcholine: black box due to K, arrhythmias, card arrest vs -Rocuronium: longer acting but reversal agent soon (Sugammadex-acts in 1-2 min)* IO time *Puhringer, Anesthesiology Atropine? -bradycardia risk -< 1 year old or if use succinylcholine Airway ALS: RSI Cricoid pressure? -reduce gastric air/aspiration but also distort airway ALS: safety and value not clear so let up if needed NC O2 during intubation?: -kid data scant but why not? Airway ALS: The tube Narrowest portion of airway below cricoid ring Who needs a cuff? Uncuffed under 6 years unless air leak control critical: 4
5 What if he didn t look so bad... Non-invasive ventilation Non-invasive ventilation? CPAP or PPV Face mask, nasal mask* or helmet* Improve gas exchange and decrease work of breathing Indications: >1 yr, hypoxic, not in resp failure -pneumonia, bronchiolitis, asthma Contraindications: AMS, vomiting, impaired gag, advanced resp failure, HD instability Limited studies: Try it early Case 4: Is he 5 or 15? 5 yo morbidly obese fever/sob x 2 days VS: RR 40, O2 88% on NRB, HR 150 PE: tripoding, BS with crackles both bases, no wheeze What next? Direct laryngoscopy? Maybe not... Alternatives to the ETT LMA Classic LMA Proseal LMA Supreme LMA Fastrach: intubating(>10yrs) Combitube (>4 feet tall) Alternatives to direct laryngoscopy Lighted stylet (e.g. Trachlight) 5
6 LMA: Love My Airway LMA Classic: -basic model, reusable - 90% 1st pass/99% overall (lower in infants) -complication rate <10% (infants ) Proseal: 2nd generation -reusable, gastric port, bite block -better seal than Classic -slightly lower 1st pass success LMA Supreme: -single use -curved like fastrach for easy insertion -gastric port LMA Fastrach -intubating ->30kg only Direct laryngoscopy: so retro! Stylets: slip tube over Lighted stylet (e.g. Trachlight, Tube Stat): -good with secretions but not edema/masses -look for light mid neck Optical stylet (e.g Shikani, Levitan): -shapeable with fiberoptic scope - secretions are the enemy -use w/ or w/o laryngoscope Airway video games Glidescope, Airtraq, Storz See around the corner: No need for direct line of sight to see glottis/place tube Great for c-spine patients Secretions/blood are a killer Tendency to focus on monitor oral trauma 6
7 Do video games work better? 200 kids 3 mo-17 yrs direct laryngoscopy vs. Glidescope Improved view but 97 vs 90% 1st pass success Took longer (24 vs 36 sec) Can t intubate/can t ventilate!! 8 month old with respiratory distress Respiratory arrest! -BVM: unable to ventilate -Reposition/suction/oral airway still unable to ventilate What next??? Kim, et al, Br J Anesth 2008 Airway disaster plan When is it time to go to the neck? BVM Laryngoscopy LMA GO TO THE NECK Can t intubate/can t ventilate All attempts at oxygenation are failing Child not waking up soon Vitals deteriorating due to hypoxia 7
8 Big guys vs. little guys Cricothyroid membrane: -13 x 12 mm (adult) vs -2.5 x 3 mm (neonate)!! Landmarks tough >8 years: surgical or percutaneous approach <8 years: needle/catheter only Needle cricothyroidotomy Extend neck with roll, adipose towards mandible, quick prep Any tracheal site below thyroid cartilage 14G angiocath on 10cc syringe (or Ventilation Catheter <VBM, Germany>) Insert until free flow air then advance catheter Jet ventilation Trans-tracheal ventilation Pseudo-jet ventilation: -Cook tubing connects to angiocath and 15 l/min O2 -Macgyver: cut sideholes into oxygen tubing Pediatric airway pitfalls Failure to monitor properly and understand airway BLS Failure to anticipate difficult airway and have range of equipment available Bag ventilation: ETT adapter ETT adapter inserted in 3cc syringe barrel Allow time for passive exhalation-2:1 ratio Failure to practice alternative techniques Prolonged attempts trauma/bleeding in airway Spending too long placing IV go to IO Failure to move to the neck when all else fails 8
9 9
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