Pediatric airway management winkler

1. Pediatric Airway Pediatric Airway
ManagementManagement
Margaret Winkler, MDMargaret Winkler, MD
Pediatric Critical CarePediatric Critical Care
University of Alabama at University of Alabama at
BirminghamBirmingham

2. The Pediatric AirwayThe Pediatric Airway
IntroductionIntroduction
Anatomy / PhysiologyAnatomy / Physiology
PositioningPositioning
AdjunctsAdjuncts
IntubationIntubation

3. IntroductionIntroduction
Almost all pediatric “codes” are of Almost all pediatric “codes” are of
respiratory originrespiratory origin
Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

4. Pediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary Arrests
1° Respiratory
Shock
1° Cardiac
10%10%
80%80%

5. Age distribution of arrestsAge distribution of arrests
0
5
10
15
20
25
30
35
40
<7 mos
151413121110987654321
7-12 mos
Age (years)
# Arrests

6. Schindler M, et al. Outcome of out-of-hospital cardiac or Schindler M, et al. Outcome of out-of-hospital cardiac or
respiratory arrest in children. N Engl J Med 1996;335:1473-1479.respiratory arrest in children. N Engl J Med 1996;335:1473-1479.
Arrive in ER in Arrive in ER in
cardiac arrestcardiac arrest
(N = 80)(N = 80)
Admit PICUAdmit PICU
(N=43) 54 %(N=43) 54 %
Died in ERDied in ER
(N=37) 46%(N=37) 46%
Mod DeficitMod Deficit
(N=3)(N=3)
PVS at PVS at
12 mos12 mos
(N=2)(N=2)
Dead at Dead at
12 mos12 mos
(N=1)(N=1)
Died in ICUDied in ICU
(N=37) 46%(N=37) 46%

7. AnatomyAnatomy
Children are very different than adults !!!Children are very different than adults !!!

8. Anatomy : NoseAnatomy : Nose
•Nose is responsible for 50% of total airway Nose is responsible for 50% of total airway
resistance at all agesresistance at all ages
•Infant: blockage of nose = respiratory Infant: blockage of nose = respiratory
distressdistress

9. Anatomy : TongueAnatomy : Tongue
•LargeLarge
•Loss of tone with sleep, sedation, CNS Loss of tone with sleep, sedation, CNS
dysfunctiondysfunction
•Frequent cause of upper airway obstructionFrequent cause of upper airway obstruction

10. Anatomy : LarynxAnatomy : Larynx
•High positionHigh position
•Infant : C 1Infant : C 1
•6 months: C 36 months: C 3
•Adult: C 5-6Adult: C 5-6
•Anterior positionAnterior position

11. Children Children areare different different

12. Anatomy : LarynxAnatomy : Larynx
Narrowest point = cricoid cartilage in the childNarrowest point = cricoid cartilage in the child

13. Anatomy : EpiglottisAnatomy : Epiglottis
•Relatively large size in childrenRelatively large size in children
•Omega shapedOmega shaped
•Floppy – not much cartilageFloppy – not much cartilage

14. Physiology: ResistancePhysiology: Resistance
Peripheral airways contribute to total airways Peripheral airways contribute to total airways
resistance:resistance:
AdultAdult 20%20%
ChildChild 50%50%

15. Physiology: Effect of EdemaPhysiology: Effect of Edema
Poiseuille’s lawPoiseuille’s law
If radius is If radius is halvedhalved, resistance increases , resistance increases 16fold16fold
R =R =
8 n l8 n l
PP rr
44

17. Airway positioning for Airway positioning for
children <2yrschildren <2yrs

19. Airway PositioningAirway Positioning
““Sniffing Position”Sniffing Position”
In the child older than 2 yearsIn the child older than 2 years
Towel is placed under the headTowel is placed under the head

21. Airway adjunctsAirway adjuncts
•Nasal airwayNasal airway
•Oral airwayOral airway

22. Nasopharyngeal AirwayNasopharyngeal Airway
Contraindications:Contraindications:
Basilar skull fractureBasilar skull fracture
CSF leakCSF leak
CoagulopathyCoagulopathy
Length: Nostril to TragusLength: Nostril to Tragus

23. Endotracheal tube as nasal airwayEndotracheal tube as nasal airway
A regular ETT A regular ETT
can be cut and can be cut and
used as a nasal used as a nasal
airway airway

24. Adjuncts: Oral AirwayAdjuncts: Oral Airway
Wrong size: Too LongWrong size: Too Long

25. Adjuncts: Oral AirwayAdjuncts: Oral Airway
Wrong size: Too ShortWrong size: Too Short

26. Adjuncts: Oral AirwayAdjuncts: Oral Airway
Correct sizeCorrect size

27. Oral AirwaysOral Airways

29. Signs of Respiratory DistressSigns of Respiratory Distress
•TachypneaTachypnea
•TachycardiaTachycardia
•Grunting Grunting
•StridorStridor
•Head bobbingHead bobbing
•FlaringFlaring
•Inability to lie downInability to lie down
•AgitationAgitation
•RetractionsRetractions
•Access musclesAccess muscles
•WheezingWheezing
•SweatingSweating
•Prolonged expirationProlonged expiration
•Pulsus paradoxusPulsus paradoxus
•ApneaApnea
•CyanosisCyanosis

31. Impending Respiratory FailureImpending Respiratory Failure
•Reduced air entryReduced air entry
•Severe workSevere work
•Cyanosis despite OCyanosis despite O
22
•Irregular breathing / apneaIrregular breathing / apnea
•Altered ConsciousnessAltered Consciousness
•DiaphoresisDiaphoresis

32. Respiratory FailureRespiratory Failure
•Hypoxic respiratory failureHypoxic respiratory failure
•Hypercarbic respiratory failureHypercarbic respiratory failure

33. HypoxemiaHypoxemia
•Inadequate inspiratory Inadequate inspiratory
partial pressure of oxygenpartial pressure of oxygen
•Global alveolar Global alveolar
hypoventilationhypoventilation
•Right to left shuntRight to left shunt
•V/Q mismatchV/Q mismatch
•Incomplete diffusion Incomplete diffusion
equilibriumequilibrium
•Low barometric pressure or Low barometric pressure or
FIO2FIO2
•High PaCO2High PaCO2
•Little change with extra oxygenLittle change with extra oxygen
•Good response to O2Good response to O2
•Good response to O2Good response to O2
MechanismMechanism Distinguishing AttributeDistinguishing Attribute

34. Incomplete diffusion equilibriumIncomplete diffusion equilibrium
•Thickened alveolocapillary membrane (true Thickened alveolocapillary membrane (true
diffusion block)diffusion block)
•Abnormally low oxygenation of mixed Abnormally low oxygenation of mixed
venous blood venous blood
•Lung damage or destruction, resulting in Lung damage or destruction, resulting in
reduced alveolar capillary volumereduced alveolar capillary volume
•Increased CO with reduced alveolar Increased CO with reduced alveolar
capillary transit timecapillary transit time

35. Intubation: IndicationsIntubation: Indications
•Failure to oxygenateFailure to oxygenate
•Failure to remove COFailure to remove CO
22
•Increased WOBIncreased WOB
•Neuromuscular weaknessNeuromuscular weakness
•CNS failureCNS failure
•Cardiovascular failureCardiovascular failure

36. IntubationIntubation
•Larynx cephalad and anterior in Larynx cephalad and anterior in
childrenchildren
–Practitioner may need to be Practitioner may need to be lowerlower
than patient and than patient and look uplook up

37. Cephalad and anteriorCephalad and anterior

38. Laryngoscope BladesLaryngoscope Blades
Macintosh
Miller

39. Intubation TechniqueIntubation Technique
Straight Laryngoscope Blade – used to pick up Straight Laryngoscope Blade – used to pick up
the epiglottisthe epiglottis
Better in younger Better in younger
children with a children with a
floppy epiglottisfloppy epiglottis

40. Intubation TechniqueIntubation Technique
Curved Laryngoscope Blade – placed in the valleculaCurved Laryngoscope Blade – placed in the vallecula
Better in older Better in older
children who children who
have a stiff have a stiff
epiglottisepiglottis

41. IntubationIntubation






AgeAge kgkg ETTETT Length (lip) Length (lip)
NewbornNewborn3.53.5 3.53.5 99
3 mos3 mos 6.06.0 3.53.5 1010
1 yr1 yr 1010 4.04.0 1111
2 yrs2 yrs 1212 4.54.5 1212
Children > 2 years:Children > 2 years:
ETT size: ETT size: Age/4 + 4Age/4 + 4
ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

42. Technique: IntubationTechnique: Intubation
How far does How far does
it go in ?it go in ?

43. Deterioration after IntubationDeterioration after Intubation
•DDisplaced tubeisplaced tube
•OObstructed tubebstructed tube
•PPneumothoraxneumothorax
•EEquipmentquipment