PEDIATRIC AIRWAY EVALUTAION & MANAGEMENT

Why so important?

80%

10%

10%respi-ratory

cardiac

shock

Majority < 1 year old

Upper airway obstruction:- infectious disease (90%), viral croup

(80%) Epiglottitis (5%) 5% - F.B, external trauma &

congenital anomaly

Airway – passage through which air passes during respiration

pediatric airway ×mini adult airway

Nasal & oral cavity

Pharynx & larynx

Trachea & large bronchi

large occiputObligate nasal breathersLarge tongueHigher placed larynxAnteriorly angulated

vocal cords

Anatomical features of pediatric airway

• Differently shaped epiglottis

• Funnel shaped larynx

• Narrowest part is cricoid

• 4-5.5mm

Work of breathing for each kg BW is same in infant& adult O2 consumption 6l/kg/min in children and 3ml/kg/min in

adult Greater O2 consumption- inc RR Tidal volume is relatively fixed ( 6-7ml/kg/min) MAV is more dependent on RR then tidal volume

(130ml/kg/min) MAV/ FRC is double , so during hypoxia ,apnea &

anesthesia , desaturation occurs rapidly Poiseuille,s law

EvaluationAge :- laryngomalacia( birth) ALTB ( <3yrs) F.B ( <15ys) Epiglottitis ( 2-6 yrs), retropharyngeal abscess ( 1-4 yr)

Presenting c/o : dyspnoeaNoisy breathing – onset

ProgressionVariabilityAssociation with sleep, crying, feedingOther aggravating & relieving factors

Associated or preceding URI, fever.h/o chocking episode, Fb intakeCOUGH:- nature

OnsetProgressionAggravating & reliving factors

VOICE changeDifficult feedingCyanosisNeck swellingh/o asthma & repeated pneumoniah/o intubation, birth trauma

General appearance of child with careful attention:Level of consciousness:- Decrease interactionIrritabilityRestlessAnxious Diaphoresis

Examination

Air hunger and hypoxemia

Increase work of breathing:Respiratory rateNasal flaringChest retractionsAccessory muscle useHead bobbingGruntingTripod position

Nose – mucus , swellingTongue, craniofacial anomalyVomitus, bleeding, Secretions in mouthAbnormal airway sounds:- stridor

StertorWheezeGrunting

Inspiratory or expiratoryCirculation:- pallor, cyanosis , skin temperature & auscultatton.

Local examination

Craniofacial anomalies

Pierre Robin S.

Treacher Collins S.

Down S.Cruzon syndrome

suctioning, positioning & supportive care are the key elements.

Stabilization of airway is primary importance during initial resuscitation.

Goal of airway management :- relieve anatomical obstruction. prevent aspiration Promote adequate gas exchange

MANAGEMENT

ACUTE AIRWAY MANAGEMENT:-

Suction nose & nasopharynx

Positioning:- reposition/ allow child to assume position of comfort

Head tilt, chin lift/ jaw thrust position

Oxygen therapy:- reduces the ventilatory requirement of oxygen.

cardiac & respiratory arrest. Hypoxemia Metabolic acidosis Respiratory distressBlood pressure, O2 saturation .

Nebulization with adrenaline (1:3) or bronchodilators.

Humidification/ steroidHeliox mixture:- 79% He and 21% O2Oropharyngeal/ bag and mask ventilatioEmergency airway access:-Intubation/

tracheostomy

Oropharyngeal airway

Bag and mask ventilation

Endotracheal tube

Tracheostomy tube

Imp laboratory test is ABGPaO2- 80-100 mm hgPaCo2- 40±5 mm hgpH- 7.40± 0.05O2 sat- >95%CBC, SE

RADIOLOGICAL - not done routinely

Xray STN lateral viewXray chest AP viewXray chest lateral oblique viewCT scan- choanal atresia

Investigations

Acute airway conditions:-Epiglottitis:- stabilize the childAvoid taking blood sample/ chest x rayAnesthetic induction-sitting positionEndotracheal intubationTracheostomy.Laryngotracheobronchitis:- O2 therapy Humidification nebulization with adrenaline Steroid/ antibiotics intubation

RETOPHARYNGEAL ABSCESS:-Maintaining airwayAntibioticsIncision & drainage

Foreign Body airwayBronchoscopy and removal

Endoscopic evaluation:-Nasopharyngolaryngoscopy

Laryngotracheoscopy

Microlaryngoscopy- gold standard

bronchoscopy

Sub acute conditions

Access nares/ choana, adenoid , lingual tonsilDynamic study access laryngeal structuresCan be used under LA & bedsideThick tongue base, overhanging epiglottis &

laryngeal scarsHigh cost & less manipulation.Less compliance

Flexible laryngoscopes

Doesn’t require GAMainly diagnostic purposeLimited interventionCan be used for intubationLimited airway control

Flexible bronchoscopy

Requires GABetter airway controlEasier interventionLaryngoscopeVentilating bronchoscopeHopkins rod telescopeOperating microscope

Micro-laryngo-bronchoscopy

MICROLARYNGOSCOPY

Spontaneous resolution 18months- 2yearsSurgical intervention:- late onset >2 yrs10% severe laryngomalacia – failure to

thrive,hypoxemia, osa, pulmonary hypertension.

supraglottoplasty or laser epiglotopexy

laryngomalacia

Glottic web: anterior or posteriorEndoscopic laser , scissors followed by stent

palcement

Vocal cord palsy:- U/L palsy – observationRarely intubation

B/L vocal cord palsy:- tracheostomy

At least for 2 years- spontaneous recovery in half of the Patients

Vocal cord lateralization

. Congenital Subglottic stenosis: lumen diameter <4mm in term & <3mm in preterm

resolves spontaneously with growth

Tracheostomy with decannulation at 3-4 years

Laser ablation if thickness <5mm

Laryngotracheoplasty- severe cases

Acquired subglottic stenosis: Initially- steroidsMild glanular stenosis- serial endoscopic

dilatation with or without steroid injectionCO2 laser- circumferential soft stenosisOpen surgical resection – grade III & IVLaryngotracheoplastyLaaryngotracheal reconstructionstenting

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