Pediatric Airway Management

Sunsiree Santana MD

Pediatric Critical Care

Epidemiology of cardiac arrest in children

Approximately 16,000 American children suffer cardiac arrest each year

Incidence of 20/100,000 children One half younger than 1 year of age 76% younger than 4 years Male predominance

Ann Energ Med .1999 Ann Energ Med .1999

Etiologies

SIDS

Trauma

Submersion

Cardiac diagnosis

Sepsis

Asphyxia

Almost all pediatric “codes” are of respiratory origin

Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

Pediatric cardiac arrest

Most often secondary to evolving respiratory failure, with cardiac arrest resulting from lack of cellular substrate rather than from a sudden cardiac event.

The ABC’s of CPR

Asses responsiveness

If no response open the airway: look, listen and feel for breathing

If no breathing: give 2 rescue breaths

Asses for signs of circulation

If no signs of circulation begin chest compressions

Continue “pump and blow” for 1 min

911

PALS Provider Manual. AHA .2002

Airway

• Stabilization of airway is of primary importance during the initial resuscitation of the critically or injured child.

• No matter the cause or underlying condition, further attempts at resuscitation or treatment will fail without proper control of the airway.

Goals of airway management

• Relieve anatomic obstruction

• Prevent aspiration of gastric contents

• Promote adequate gas exchange

Airway management

1. Proper positioning of the head

– Protection of cervical spine

– The most common cause of airway obstruction in children: collapse of the tongue and soft tissues

Proper head positioning

Head positioning

““Sniffing Position”Sniffing Position”

In the child older than 2 In the child older than 2 yearsyears

Towel is placed under the Towel is placed under the headhead

Airway adjuncts

• Nasopharyngeal airway– Used if the patient is semiconscious

• Oral airway

• Relieve obstruction by lifting the tongue from the soft tissues of the posterior pharynx

Nasopharyngeal Airway

Contraindications:Contraindications: Basilar skull Basilar skull

fracturefracture CSF leakCSF leak CoagulopathyCoagulopathy

Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus

Oral Airways

Adjuncts: Oral Airway

Correct sizeCorrect size

Adjuncts: Oral Airway

Wrong size: Too ShortWrong size: Too Short

Adjuncts: Oral Airway

Wrong size: Too LongWrong size: Too Long

Tracheal intubation

• Indications– Respiratory failure– Upper airway obstruction– Shock or hemodynamic instability– Neuromuscular weakness– Absent protective airway reflexes– Cardiac arrest (drugs administration)

Signs of Respiratory Failure

• Tachypnea• Tachycardia• Grunting • Stridor• Head bobbing• Flaring• Inability to lie

down• Agitation

• RetractionsRetractions• Access musclesAccess muscles• WheezingWheezing• SweatingSweating• Prolonged Prolonged

expirationexpiration• ApneaApnea• CyanosisCyanosis

Anatomy

Children are very different than adults !!!Children are very different than adults !!!

Anatomy

• Tongue

• Larynx• High position

• Infants : C2-C3• Adults: C4-C5

• Anterior position

• Tracheal intubation requires the alignment of 3 axes:– Oral axis– Pharyngeal axis– Laryngeal axis

Anatomy : Epiglottis

• Relatively large size in children– Short, narrow

• Floppy – not much cartilage

Laryngoscope Blades

Macintosh

Miller

Intubation Technique

Straight Laryngoscope Blade – used to Straight Laryngoscope Blade – used to pick up the epiglottispick up the epiglottis

Better in Better in younger children younger children with a floppy with a floppy epiglottisepiglottis

Intubation Technique

Curved Laryngoscope Blade – placed in the Curved Laryngoscope Blade – placed in the valleculavallecula

Better in Better in older children older children who have a who have a stiff epiglottisstiff epiglottis

Anatomy : Larynx

Narrowest point = cricoid cartilage in the child

Intubation

• Larynx cephalad and anterior in children

– Practitioner may need to be lower than patient and look up

Intubation

AgeAge kgkg ETTETT Length (lip) Length (lip)

NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Technique: Intubation

Critically ill or injured child should be assumed to have a full stomach and are at risk for

regurgitation and aspiration of gastric content.

Rapid sequence intubation

Rapid sequence intubation

• Keys

1. Pre-oxygenation

2. Sellick’s maneuver

3. Medications

Rapid-acting neuromuscular blocker

Sedation

Medications

Benzodiazepines

Midazolam (Versed): 0.1-0.2mg/kg

Narcotics

Fentanyl : 1-2 mg/kg

Morphine: 0.1mg/kg

Medications

Ketamine: 1mg/kgBronchodilatorIncreases BP, cerebral blood flow & ICP

EtomidateThiopentalNeuromuscular blocking agents

Vecuronium(Norcuron): 0.1mg/kg

Deterioration after intubation

• Displaced tube

• Obstructed tube

• Pneumothorax

• Equipment

Thanks!