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Pediatrics

Pediatric Airway Management

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ObjectivesBy the end of this workshop, the learner will:

‐Recite at least 3 indications and 5 complications associated with orotracheal intubation

‐Derive the appropriate ETT size for orotracheal intubation using a formula and/or the patient’s age/weight/size

‐Determine the appropriate sized laryngoscopy blade according to the patient’s age/weight/size

‐Carry out the proper sequence of events involved in orotracheal intubation

Pediatrics

Preparing for Intubation


Indications for Intubation

• Primary respiratory disorder

‐ Severe hypoxemia (pneumonia, ARDS)

‐ Severe hypoventilation (bronchiolitis, emphysema, CLD)

• Primary neuromuscular disorder

‐ Myopathy (DMD, SMA)

‐ Altered mental status with hypoventilation (TBI, intoxication)

‐ Lack of airway protection (TBI, severe HIE, intoxication)

‐ Need for sedation with risk of airway protection or ventilation

• Tight control of paCO2 or pH

‐ Severe increased ICP (paCO2)

‐ Severe pulmonary hypertension (pH)

• To reduce metabolic demands in severe shock


Use SOAP to Prepare for Intubation

•Suction

‐Rigid catheter with constant suction (Yankauer)

•Oxygen

‐10-15 LPM 100% (make sure it is not on a blender)

•Airway

‐Appropriate sized tubes (estimated size and ½ size smaller)

‐Appropriate sized laryngoscope blades

‐Airway adjuncts

•Pharmacology

‐Based on disease

www.m

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Medications for Intubation

•Premedication for laryngoscopy

•Sedation +/- analgesia

•Neuromuscular blockade‐Make sure you can ventilate prior to neuromuscular blockade

‐Make sure you can ventilate prior to neuromuscular blockade



Premedication

•Atropine (neonates, infants)‐0.02 mg/kg IV (0.1 – 1 mg total dose)

‐Blunts the vagal response from laryngoscopy

‐Use if bradycardic/risk of bradycardia

•Lidocaine (TBI, elevated ICP)‐1 mg/kg IV

‐Anesthetizes airway to blunt the ICP spike from laryngoscopy

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Sedation•Midazolam (85% of routine patients)

‐ 0.1 – 0.2 mg/kg IV

•Fentanyl (85% of routine patients)

‐ 2 – 6 mcg/kg IV (slow infusion, may cause rigid chest)

‐ Give sedative with fentanyl (no sedative effect)

•Propofol

‐ 1 mg/kg IV (may cause hypotension)

•Ketamine (shock states, asthma)

‐ 1 – 3 mg/kg IV (may cause increased bronchorrhea)

‐ 2 mg/kg IV for RSI

•Thiopental vs. Etomidate (elevated ICP)

‐ Thiopental 3 – 5 mg/kg IV (high risk of hypotension)

‐ Etomidate 0.2 – 0.6 mg/kg IV (may cause adrenal suppression)


Neuromuscular Blockade•Rocuronium vs. Vecuronium (85% of patients)

‐ Rocuronium 0.6 – 1.2 mg/kg IV (1.5 – 2 mg/kg IV for RSI)

‐ Vecuronium 0.1 – 0.4 mg/kg IV

‐ Effect may be prolonged in renal/hepatic failure

•Cisatracurium

‐ 0.2 mg/kg IV

‐ Cleared by Hoffman degradation (good for renal/hepatic failure)

•Succinylcholine

‐ 1 – 2 mg/kg IV; 4 mg/kg IM

‐ Patient will fasciculate, consider a defasciculating dose of rocuronium/vecuronium (1/10 dose)

‐ Beware of hyperkalemia in patients with neuromuscular disorders, burns, crush injuries, renal failure

Pediatrics

Orotracheal Intubation


Laryngoscope and ETT Selection

•Match the patient! If the patient is smaller than stated age (or unknown age), ETT can be estimated by the patient’s 5 th finger size

Age Blade Size & Type ETT Size (mm; Uncuffed & Cuffed)

NB < 2 kg 0 Miller 2.5

NB > 2 kg ~ 6 mo 1 Miller 3.5 or 3.0 C

6 mo ~ 1 yr 1 ~ 1.5 Miller 4.0 or 3.5 C

1 yr ~ 2 yr 1.5 Miller 4.5 or 4.0 C

2 yr ~ 8 yr 2 Miller For UNcuffed tubes:

8 yr ~ 12 yr 2 Miller or 2 Macintosh

> 12 yr 3 Miller or 3 MacintoshAge(yrs)

4+ 4 Subtract 0.5 mm

for Cuffed tubes


Choose Your Blades

Miller Blades Macintosh Blades


http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259

Head Tilt-Chin Lift Maneuver


Alignment of The Airway:Children <3 years

McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249‐84

O: Oral axisP: Pharyngeal axisL: Laryngeal axis

Large occiput flexes head and neck Shoulder roll will

help line up the pharyngeal and laryngeal axes

Extension of atlantooccipital joint will line up oral axis with the other two


Placement of the Laryngoscope Blade (< 3 years)

From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001

Shoulder Roll for Infants


Alignment of The Airway:Children >3 years

McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84

O: Oral axisP: Pharyngeal axisL: Laryngeal axis

Cushion under head will flex neck to line up pharyngeal and laryngeal axes

Extension of atlantooccipital joint will line up oral axis with the other two


Placement of the Laryngoscope Blade (> 3 years)

From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001


Laryngoscopic View

From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right)

http://www.bartleby.com/107/236.html


ETT Insertion Depth – How Far?

•3 x ETT size

•Black marking or cuff past vocal cords

Pediatrics

Post-Intubation Care


How Do You Confirm Intubation?

•Bilateral & equal breath sounds

- If decreased on one side?

- If absent on one side and hypertympanic

•Improvement of oxygenation

- If saturations rapidly decrease?

•EtCO2 confirmation

- Colorimetric: Yellow = Yes

- Waveform analysis/quantitative: > 15 mm Hg

•CXR confirmation

•Absent sounds over stomach

•Mist in ETT during bag-ventilation


•Inability to ventilate (difficulty intubating and cannot BMV)

‐This can lead to death


•Tube malposition (esophageal intubation)

‐What will you notice/see?

Potential Complications of Oral Intubation


•Airway trauma

‐Teeth (check for loose or missing teeth before and after)

‐Vocal cord injury (ineffective paralytic/VC closed during insertion)

‐Subglottic edema/stenosis (incorrect tube size)

•Pulmonary disease

‐Mainstem (left or right) intubation

‐Pneumothorax (usually from over-exuberant bagging)

Potential Complications of Oral Intubation


Pneumothorax

From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)

http://www.ambu.com/


Dental Trauma (DON’T DO THIS)

From: Windsor and Lockie. Anaesth and Int Care Med. 2008

Pediatrics

NOW WATCH IT DONE

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