THE DIFFICULT PEDIATRIC AIRWAY. Learning Objectives. The Pediatric Airway 6/7/18. Jason W. Gatling, MD Department of Anesthesiology June 7, 2018
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1 THE DIFFICULT PEDIATRIC AIRWAY Jason W. Gatling, MD Department of Anesthesiology June 7, 2018 Learning Objectives At the conclusion of this activity, the participants should be able to: 1. Describe what makes a pediatric airway different 2. Describe risk factors for difficult airway in pediatrics 3. Describe the American Society of Anesthesiology Difficult airway algorithm 4. Describe ventilation techniques 5. Describe intubation techniques The Pediatric Airway 1. Anatomy 2. Physiology 3. Airway evaluation 4. Management of normal vs. abnormal airway 5. Difficult airway 1
2 5 Differences between the Pediatric and Adult Airway 1. More rostral larynx 2. Relatively larger tongue 3. Angled vocal cords 4. Differently shaped epiglottis 5. Funneled shaped larynx-narrowest part of pediatric airway is cricoid cartilage Differences Infant s larynx is higher in neck (C2-3) compared to adult s (C4-5) Differences Larger Tongue 1. Obstructs airway 2. Obligate nasal breathers 3. Difficult to visualize larynx Angled Vocal Cords 1. Infant s vocal cords have more angled attachment to trachea, whereas adult vocal cords are more perpendicular 2. Difficulty in nasal intubations where blindly placed ETT may easily lodge in anterior commissure rather than in trachea 2
3 Differences Adult epiglottis broader, axis parallel to trachea Infant epiglottis omega (Ώ) shaped and angled away from axis of trachea More difficult to lift an infant s epiglottis with laryngoscope blade Differences ADULT INFANT Funneled shape larynx 1. Narrowest part of infant s larynx is the undeveloped cricoid cartilage, whereas in the adult it is the glottis opening (vocal cord) 2. Tight fitting ETT may cause edema and trouble upon extubation 3. Uncuffed vs. cuffed ETT 4. Fully developed cricoid cartilage occurs at years of age Potential Airway Issues Apnea Asthma / Reactive airway disease / Upper respiratory infection Obesity (BMI) Tonsillar / adenoid hypertrophy Syndromes (Down, Pierre Robin, Marfan s, Mucopolysaccharidos is) Tracheal / laryngomalacia Prior tracheostomy Vascular ring Cerebral palsy/other conditions of muscle weakness Swallowing problems Severe reflux 3
4 Signs of Impending Respiratory Failure Increased work of breathing Tachypnea / tachycardia Nasal flaring Drooling Grunting Wheezing Stridor Head bobbing Use of accessory muscles / retraction of muscles Cyanosis despite O 2 Irregular breathing / apnea Altered consciousness / agitation Inability to lie down Diaphoresis Bag-Mask Ventilation Clear, plastic mask with inflatable rim provides atraumatic seal Proper area for mask applicationbridge of nose extend to chin Maintain airway pressures <20 cm H2O Place fingers on mandible to avoid compressing pharyngeal space Continuous positive pressure when needed to maintain airway patency Oropharyngeal Airway SIZE PROPER POSITION 4
5 Endotracheal Tube Uncuffed ETT: (age in years/4) + 4 Cuffed ETT: (age in years/4) +3 ETT depth (lip): ETT size x 3 Abnormal Pediatric Airway 1. Congenital Neck Masses Dermoid cysts, cystic teratomas, cystic hygroma, lymphangiomas, neurofibroma, lymphoma, hemangioma 2. Congenital Anomalies Choanal atresia, tracheoesophageal fistula, tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular ring, tracheal stenosis 3. Congenital Syndromes Pierre Robin Syndrome, Treacher Collins, Turner s, Down s, Goldenhars, Apert, Achondroplasia, Crouzon Abnormal Pediatric Airway 4. Inflammatory Epiglottitis, acute tonsillitis, peritonsillar abscess,retropharyngeal abscess, laryngotracheobronchitis,bacterial tracheitis,adenoidal hypertrophy,nasal congestion, juvenile rheumatoid arthritis 5. Traumatic / Foreign Body Burn, laceration, lymphatic / venous obstruction, fractures / dislocation, inhalational injury, post-intubation croup (edema), swelling of uvula 6. Metabolic Congenital hypothyroidism, mucopolysaccharidosis, Beckwith-Wiedemann Syndrome, glycogen storage disease, hypocalcemia laryngospasm 5
6 Congenital Neck Masses Rigid Bronchoscopy Cystic Hygroma Choanal Atresia Complete nasal obstruction Occurs in 0.82 / 10,000 births During inspiration, tongue pulled to palate, obstructs oral airway Unilateral nare (right>left) Bilateral choanal atresia is airway emergency Death by asphyxia Associated with other congenital defects Pierre-Robin Sequence Occurs in 1/8500 births Autosomal recessive Mandibular hypoplasia, micrognathia, cleft palate, retraction of inferior dental arch, glossptosis Severe respiratory and feeding difficulties Associated with OSA, otitis media, hearing loss, speech defect, ocular anomalies, cardiac defects, musculoskeletal (syndactyly, club feet, CNS delay, GU defects) 6
7 Treacher Collins Syndrome Mandibulofacial dysostosis Occurs in 1/10,000 births Cheek bone and jaw bone underdeveloped External ear anomalies, drooping lower eyelid, unilateral absent thumb Respiratory difficulties Underdeveloped jaw causes tongue to be positioned further back in throat (smaller airway) Associated with OSA, hearing loss, dry eyes Down Syndrome Trisomy 21 Occurs in 1/660 births Short neck, small mouth with large protruding tongue, flattened nose Associated with congenital heart disease, subglottic stenosis, tracheo-esophageal fistula, duodenal atresia, chronic pulmonary infection, seizures, and acute lymphocytic leukemia Atlanto-occipital dislocation can occur during intubation due to congenital laxity of ligaments Inflammatory Etiology: Haemophilus influenzaetype-b Occurs in children ages 2-6 years Progresses rapidly from a sore throat to dysphagia and complete airway obstruction (within hours) Signs of obstruction: stridor, drooling, hoarseness, tachypnea, chest retraction, preference for upright position OR intubation / ENT present for emergency surgical airway Do NOT instrument airway before induction of anesthesia to avoid laryngospasm 7
8 Laryngospasm A forceful, involuntary spasm of laryngeal musculature caused by stimulation of the superior laryngeal nerve Occurs more commonly in children Occurs at light levels of sedation / analgesia Treat with positive pressure ventilation (using 100% O 2 with tightly fitting mask) Employ the Laryngospasm Maneuver If laryngospasm persists and hypoxia develops, administer Succinylcholine ( mg/kg) Laryngospasm management must be part of any procedural sedation plan (it is the most common significant complication). Laryngospasm Maneuver 70 Apply firm inward pressure bilaterally with both index fingers at the laryngospasm notch (located just behind the earlobe - the posterior aspect of the mandible). This action exerts pressure on the styloid process and induces laryngeal relaxation. q This hand positioning allows for excellent manual control of the mandible (esp. during invasive procedures threatening or involving the upper airway) Laryngospasm notch q Avoid the angle of the mandible which places the fingers too low and may threaten the carotids. Definition Difficult mask ventilation Including difficult Supraglottic Airway placement Difficult intubation Or both!! 8
9 Airway Exam Difficult Ventilation: 1. Facial hair 2. Small mandible 3. Airway masses (papillomas, tonsils, mediastinal) 4. Nasal encephalocele Difficult Intubation: 1. Craniofacial anomaly 2. Small mandible 3. Decreased mouth opening Predictors Mallampati Score 9
10 ASA Algorithm Predictors 1. Assess the likelihood and clinical impact of basic management problems: Difficulty with patient cooperation or consent Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult intubation Difficult surgical airway access 2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management 3. Consider the relative merits and feasibility of basic management choices: Awake intubation vs. intubation after induction of general anesthesia Non-invasive technique vs. invasive technique for the initial approach to intubation Video-assisted laryngoscopy as an initial approach to intubation Preservation vs. ablation of spontaneous ventilation 10
11 Airway Management Ventilation Maintain spontaneous ventilation Mask ventilation skills Oral pharyngeal airway (OPA) Nasal pharyngeal airway (NPA) Two handed mask ventilation Laryngeal mask airway (LMA) Laryngoscopy Non-Emergency Pathway Intubation Laryngoscopy Fiberoptic intubation Airtraq Shikani Rigid bronchoscopy (ENT) LMA & fiberoptic scope Glidescope Laryngoscopy 11
12 Laryngoscopy Case series 6 infants with PRS Conventional laryngoscopy n grade 3-4 view n Failed intubation Paraglossal / Bougie n Successful intubation: 5/6 Fiberoptic Bronchoscopy Air-Q LMA 12
13 AirTraq Optical Laryngoscope Optical laryngoscope 5 mo, 4.8 kg PRS Lap nissen Miller 1 n Cormack-Lehane grade 3 view Airtraq 0 n Cormack-Lehane grade 1 view Shikani Scope Case series 4 patients 19 m/o with Pierre-Robin Sequence Grade 4 view Intubated in 35 seconds with Shikani LMA and Fiberoptic Scope Case series 5 neonates kg Awake LMA insertion Fiberoptic scope through LMA GA after ETT 13
14 6/7/18 LMA and Fiberoptic Scopy Glidescope Pediatric Glidescope 14
15 Emergency Pathway Can NOT Intubate & Can NOT Ventilate Supraglottic (non-invasive) LMA i-gel King airway Rigid bronchoscopy Subglottic (invasive) Cricothyrotomy, Transtracheal jet ventilation Tracheostomy Consider ECMO? Take Home Message Planning is everything Don t burn your bridges Always proceed with caution Always call for more help! 15
16 Thank you very much for the opportunity to share with you today! 16
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