Recognizing the Difficult Airway in Pediatric Patients. Nancy L. Glass, MD, MBA,

Transcription

1 Recognizing the Difficult Airway in Pediatric Patients Nancy L. Glass, MD, MBA,

2 None Disclosures

3 Learning Objectives At the end of this presentation, participants will be able to: Correlate the patient s physiognomy with airway function Identify common pediatric syndromes associated with a difficult airway Formulate a plan for managing the difficult pediatric airway, using commonly available tools

4 Anatomy of the Difficult Airway Identifying the site of the problem is key to planning management

5 Anatomy of the Difficult Airway Extrinsic compression, swelling Malposition of craniofacial structures in relation to larynx Deposition of abnormal material in or around the airway

6 Anatomy of the Difficult Airway Minimal acute disease can have a major impact on the anatomically abnormal airway

7 Airway edema / secretions Effect of 1 mm edema on airway area Resistance to turbulent flow 32X Resistance to turbulent flow 5X From Coté, A Practice of Anesthesia for Infants and Children, 2 nd edition

8 The Difficult Airway..Not necessarily the same as a difficult intubation

9 Anatomy of the Difficult Airway The airway that was easy last time may not be easy now and vice versa.kids change!

10 Why do kids turn blue So Fast? Low FRC (oxygen reserves) High oxygen consumption Adults 3-4 ml/kg/min Infants 6-8 ml/kg/min And it seems like it takes FOREVER for the O2 sat to recover after an unsuccessful laryngoscopy

11 The Difficult Pediatric Airway Foreign bodies Congenital anomalies Airway masses Acquired conditions Photos of patients will be used to illustrate key findings in each category, and to suggest strategies for securing/managing the airway

12 Foreign Bodies

13 Suspicion of Foreign Body Acute vs. chronic Sudden onset distress / coughing, vs. unusual or repeated pneumonia Distress while eating Sudden distress while playing alone Distress after falling onto hard or pointed objects, w or w/o subcutaneous emphysema

14 Kinds of Foreign Bodies Radio-opaque: metal, sharp or smooth, penetrating or not Food: large obstructing bolus, or small pieces organic material, causing inflammatory reactions Unusual and/or iatrogenic

15 Anesthetic Considerations Shared airway procedure Obstructing lesion makes induction a challenge TIVA vs inhalation? Instrument the airway, or spontaneous ventilation? Airway may be WORSE after FB removed!

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17 Which picture is missing?

18 Trachea or esophagus? Other possibilities? What do you want to know about this object?

19 LOOK FOR BLEEDING or TEAR after object removed!

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23 Congenital Anomalies

24 Key Facial Features Head size / shape Jaw mobility Mouth size / opening Midface hypoplasia Neck length / circumference / mobility

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26 BEWARE THE FLAT MIDFACE: ANTERIOR LARYNX

27 Mucopolysaccharidoses: ALWAYS get worse with age!

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29 BEWARE the asymmetric face / jaw

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35 Nasal Trumpet Great for delivering oxygen and volatile agent during laryngoscopy, or if mask fit is difficult

36 Kids who do not eat (chew) and do not speak are at HIGH RISK for having poor jaw mobility

37 What s the hard part of managing her airway?

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39 Airway Masses

40 Types of Airway Masses External compression Internal masses Effect of loss of airway muscle tone on obstruction

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46 Effective Control of Tongue: Tongue Stitch Towel Clip

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48 and from Guatemala

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52 Yep, they want a bx: now what?

53 Acquired Airway Problems

54 Acquired Airway Problems Infectious problems Obesity Trauma Progression of storage diseases Miscellaneous

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56 What is it? How do you manage it?

57 Epiglottitis Positive pressure to stent airway open Spontaneous ventilation Drying agent Sedation? IV? Sitting induction? Helium? Parental presence?

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60 Just intubate thro an LMA

61 Videolaryngoscope TIP: In pediatrics, much more useful for NECK immobility than JAW immobility

62 Etiology?

63 Postoperative Airway Obstruction Long prone case Patient awakened, extubated Tongue massively swollen within 10 min

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65 Hasani A, Pediatric Anesthesia, 2008

66 Anterior Posterior Dental Bite Block

67 Diagnosis? Key physical finding? Hard to do inhalation anesthetic with airway obstruction TIVA? Combination?

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69 Positioning challenges Mask fit Mouth opening Laryngoscopy Enlarged tonsils and redundant soft tissue Abnormal CO2 response; possible sleep apnea Childhood Obesity: our newest airway challenge

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73 Anatomy of a Difficult Airway Identifying the site of the problem is the key to planning your management There is no substitute for a good physical exam A Difficult Airway is not necessarily the same as a difficult intubation

74 Anatomy of a Difficult Airway Minimal acute disease can have a major impact on the anatomically abnormal airway Kids change with age: airway may get easier or harder!

75 Helpful Adjuncts / Tricks Medications Drying agents Lidocaine spray Steroids Spontaneous ventil: Sevoflurane Ketamine Dexmedetomidine Propofol Tools Nasal trumpet Tongue stitch Good head/neck positioning LMAs Glidescope Fiberscope

76 Good mask ventilation trumps a flailed intubation every time! And a BAD airway beats NO airway at all: so keep em breathing!