Lecture 2 (Part 2)-Respiratory A&P In Infants And Children Flashcards
Pediatric airway anatomy—___ (small/large) head, ___ (long/short) neck, ___ (small/large) tongue which can easily obstruct airway
Large head, short neck, large tongue
Deciduous teeth erupt at __ months of age; begin shedding between ___-___ years of age
Erupt at 6 months of age; begin shedding between 6-8 years of age
Pediatric airway—epiglottis is ___ (wider/narrower), ___ (shorter/longer), and at a more ___ angle from the trachea, making it more difficult to lift
Epiglottis is narrower, longer, and at a more acute angle from the trachea, making it more difficult to lift
Typically use ___ blade in kids—put blade in the vallecula, ___ the epiglottis up so it’s completely out of your way and you can see the vocal cords
Straight (Miller)—put blade in the vallecula, pin the epiglottis up so it’s completely out of your way and you can see the vocal cords
Peds—tongue is ___ (smaller/larger) in proportion to the oral cavity than in the adult
Larger
Peds—larynx is ___ (lower/higher) in the neck in neonates/children than in adults
Higher
Neonates—C2
Children—C3-C4
Adults—C5-C6
Cricoid is more ___ shaped in infants
Conically
Narrowest portion of the pediatric airway is at the ___; in adults, it’s at the level of the ___
Cricoid ring; level of the vocal cords
Trachea in children is deviated ___ (anteriorly/posteriorly) and ___ (upward/downward); it becomes anatomically similar to adults between ___ and ___ years of age
Posteriorly and downward; becomes anatomically similar to adults between 8 and 10 years of age
Occiput in children is relatively ___ (small/large) compared with the adults’; optimal intubating position is with ___ roll to prevent neck flexion in the supine position
Relatively large; optimal intubating position is with shoulder roll to prevent neck flexion in the supine position
Pediatric larynx located at ___-___
C3-C4
Adult larynx located at ___-___
C4-C5
Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is ___-___ cm or ___-___ inches
5-9 cm or 2-2.5 inches
Do not ___ the ETT once you go through the vocal cords
Bury
If the ETT does not slide in easily, do NOT ___…you need to ___ the ETT
Force it…you need to downsize the ETT
___-___ cm H2O should leak
15-25 cm H2O
Infant epiglottis is ___ shaped and angled ___ from the axis of the trachea
Omega shaped and angled away from the axis of the trachea
It is easier to lift an infant’s epiglottis with a laryngoscopic blade—T/F?
False—it is more difficult to lift an infant’s epiglottis
A small decrease in airway size (d/t edema from inflammation or trauma) will result in a ___ (small/large) increase in resistance to flow in pediatric patients
LARGE increase in resistance to flow (Poiseuille’s Law)
Infants are obligate ___ breathers until 3-5 months of age because the major source of resistance to airflow is the lower airways
Nasal
Occlusion of the nares can cause complete airway obstruction—T/F?
True—when placing mask on child, be careful not to occlude the nares
Anesthesia ___ (increases/decreases) FRC by causing peripheral airway collapse and impaired intercostal and diaphragm activity
Decreases FRC
FRC in infant is ___-___ ml/kg, adult is ___ ml/kg
Infant is 27-30 ml/kg, adult is 30 ml/kg
Infant O2 consumption is ___ ml/kg/min, which is ___x that of an adult—O2 consumption in infants is exponentially ___ than in adults, so they go through their FRC that much ___ than an adult would!!!
7-9 ml/kg/min, which is 3x that of an adult (3 ml/kg/min)—O2 consumption in infants is exponentially greater than in adults, so they go through their FRC that much faster than an adult would!!!
How to calculate ETT size for pediatrics =
(Age in years + 16) / 4… this will give you the UNCUFFED ETT size…subtract 0.5 for cuffed ETT size
Example: 4 year old = (4 + 16)/4 = 5.0 uncuffed ETT, use a 4.5 cuffed ETT
There should be an audible air leak around the tube at a pressure between ___-___ cm H2O; check this on every child, especially for longer cases
15-25 cm H2O
If you don’t have a leak up to 40 cm H2O, you need to ___ the ETT
Change the ETT
Always prepare to have your calculated tube size and ___ size smaller
1/2 size smaller—in case you meet resistance
Physical exam—assess child’s work of breathing—if nasal ___ or ___ are present, cancel the surgery (unless it’s emergent)
Nasal flaring or retractions
Physical exam—presence of upper respiratory infection within the past 2-6 weeks = significant risk of ___
Bronchospasm
If patient is wheezing, has green nasal drainage, and fever, ___ surgery
Postpone
Common airway problems—laryngospasm—caused by stimulation of the ___ laryngeal nerve, not the ___ laryngeal nerve; caused by stimulation in stage ___ of anesthesia
Superior laryngeal nerve, not the recurrent laryngeal nerve; caused by stimulation in stage 2 of anesthesia
Common airway problems—laryngospasm—caused by contraction of the ___ muscles of the larynx (___ cricoarytenoids, ___arytenoids, ___arytenoids)
Caused by contraction of the adductor muscles of the larynx (lateral cricoarytenoids, thyroarytenoids, cricoarytenoids)
Clinical causes of laryngospasm—inhalation of ___ agents; excessive ___ in the airway; presence of ___; ___ of the airway (i.e.: intubation, extubation); stimulation of the visceral nerve endings in the pelvis, abdomen, and thorax (i.e.: hernia repairs…make sure patient is under deep enough anesthesia)
Inhalation of volatile agents; excessive secretions in the airway; presence of URI; manipulation of the airway
Treatment of laryngospasm—first line = give ___ and ___ pressure at ___ cm H2O
Give propofol and positive pressure at 40 cm H2O
If propofol and positive pressure don’t break laryngospasm, give ___ + ___
Succinylcholine 0.4 mg/kg IV; 4 mg/kg IM + atropine 20 mcg/kg IM/IV
It is okay to give 40 cm H2O positive pressure through an LMA to break laryngospasm—T/F?
False— > 30 cm H2O breaks the seal of the LMA…do not give > 30…can remove LMA and give 40 cm H2O via mask
Post-intubation laryngeal edema is a potential complication of intubation in all children but the incidence is greatest in children ages ___-___
1-4
Causes of post-intubation laryngeal edema—mechanical trauma to the airway during ___; placement of a tube that is too ___ with no ___ up to 40 cm H2O
Mechanical trauma to the airway during intubation; placement of a tube that is too tight with no leak up to 40 cm H2O—this is why we check for a leak!!!
Treatment of post-intubation laryngeal edema = ___ of inspired gases; aerosolized ___; re-___; ___ (surgical airway)
Humidification of inspired gases; aerosolized racemic epinephrine (0.5 ml of 2.25% solution in 2-3 ml saline); re-intubation; tracheostomy
Epiglottitis—etiology = haemophilus influenzae type ___
B
Epiglottitis occurs in children ___-___ years of age
3-6 years of age
Epiglottitis—rapid progression of symptoms, over ___
< 24 hours
Symptoms of epiglottitis = ___phagia, ___phonia, leaning over and profusely ___, ___ stridor, respiratory ___
Dysphagia, dysphonia, leaning over and profusely drooling, inspiratory stridor, respiratory distress
Epiglottitis typically presents with high fever, > ___ degrees C
> 39
Treatment of epiglottitis = ___; urgent intubation of the trachea under ___ anesthesia—need to be in the ___; ___, ___; fluids
Oxygen; urgent intubation of the trachea under general anesthesia—need to be in the OR; antibiotics, antipyretics; fluids
Anesthetic management of epiglottitis—do nothing to ___ or ___ the child
Do nothing to upset or agitate the child…don’t want them crying and irritating the tissue even more
Anesthetic management of epiglottitis—smooth, controlled inhalation induction with ___, child in a ___ position, ___ applied to the circuit (5 of PEEP); expect a ___ (fast/slow) induction d/t the partially obstructed airway
Smooth, controlled inhalation induction with sevoflurane, child in a sitting position, CPAP applied to the circuit (5 of PEEP); expect a slow induction d/t the partially obstructed airway
Anesthetic management of epiglottitis—achieve stage ___ of anesthesia to prevent ___
Achieve stage 3 of anesthesia to prevent laryngospasm
Anesthetic management of epiglottitis—___ has to be present; they need to be available in case a surgical airway (i.e.: tracheostomy) is necessary
ENT
Anesthetic management of epiglottitis—place the child supine, intubate the trachea with a small ETT a ___ smaller than you typically would use
Size and a half smaller
Example: if a 4 year old needs a 5.0 uncuffed ETT, 4.5 cuffed ETT, then have a 3.0 cuffed ETT available for a child with epiglottitis
Anesthetic implications for epiglottitis—inflammation of the airway may enhance irritability and increase the potential for ___, ___, and ___
Coughing, breathholding, and laryngospasm
Anesthetic implications for epiglottitis—CV depressant effects of inhalation agents may be magnified r/t ___
Hypovolemia—child will be dehydrated d/t difficulty swallowing
Anesthetic implications for epiglottitis—rigid ventilating ___ and ___ equipment must be available
Rigid ventilating bronchoscope and surgical airway equipment…child may need an urgent trach/cric, depending on how bad the swelling is
Epiglottitis recovery—extubation considered when ___ and ___ fall; resolution of the swelling signaled by ___ around ETT; extubation only after direct laryngoscopy in the OR under ___ anesthesia to confirm that ___ has resolved
Temperature and white count fall; resolution of the swelling signaled by audible leak around ETT; extubation only after direct laryngoscopy in the OR under general anesthesia to confirm that swelling of the epiglottis has resolved—will do a rigid bronchoscope to examine swelling of the epiglottis
Laryngotracheobronchitis is aka ___, ___ infection
Croup, subglottic infection
Croup accounts for ___% of infectious upper airway obstruction in children
90%
Etiology of croup—___ virus type 1 and 2, influenzae ___, respiratory ___ virus
Parainfluenzae virus type 1 and 2, influenzae type A, respiratory syncytial virus (RSV)
Croup occurs in children < ___ years of age
< 2 years of age
Epiglottitis occurs in children ___-___ years of age
3-6 years
Pathology of croup—mucosal and submucosal edema within the ___ ring, ___ (increased/decreased) luminal size
Cricoid ring, decreased luminal size
Croup has a ___ onset and progression of symptoms, over ___-___ hours
Gradual onset and progression of symptoms, over 24-72 hours
Symptoms of croup—history of ___ progressing to ___ cry or ___ cough; low grade fever < ___ degrees C
History of URI progressing to hoarse cry or barking cough; low grade fever < 39 degrees C
Treatment of croup—O2 with ___; aerosolized ___—causes vasoconstriction of capillaries in subglottic mucosa, beta adrenergic bronchodilator effect; ___ (think popular nebulizer we give in ICU); ___—stabilize cell membrane integrity, decrease the release of inflammatory mediators; anti___; intubation of the trachea is ___ unless exhaustion occurs
O2 with cool aqueous mist; aerosolized racemic epi; albuterol; corticosteroids; antipyretics; intubation of the trachea is rare unless exhaustion occurs
Foreign body aspiration—most frequent site of obstruction is ___
Right mainstem
Why is the right mainstem the most common site of foreign body aspiration?—right bronchus angle is ___ degrees, left is ___ degrees—right is the pathway of ___ resistance
Right = 15 degrees, left = 45 degrees—right is the pathway of least resistance
Signs of foreign body aspiration = ___, ___, decreased air entry into ___ lung, ___ infection, ___
Cough, wheezing, decreased air entry into affected lung, upper respiratory infection, pneumonia
Treatment of foreign body aspiration—___ or ___ removal; best to remove object within ___ hours
Laryngoscopic or endoscopic removal; best to remove object within 24 hours
Anesthetic management of foreign body aspiration—induction technique depends on the severity of airway ___
Obstruction
Anesthetic management of foreign body aspiration—with airway obstruction, induce with inhalation of ___ agent and ___ while maintaining ___ ventilation
Induce with inhalation of volatile agent and oxygen while maintaining spontaneous ventilation
Anesthetic management of foreign body aspiration—without airway obstruction, ___ induction with standard agents
IV
Anesthetic management of foreign body aspiration—achieve stage ___ of anesthesia and perform direct laryngoscopy for the purpose of anesthetizing the vocal cords to prevent ___ (use lidocaine ___%, ___-___ mg/kg)
Achieve stage 3 of anesthesia and perform direct laryngoscopy for the purpose of anesthetizing the vocal cords to prevent laryngospasm (use lidocaine 1%, 1-2 mg/kg)
Foreign body aspiration—with airway obstruction, avoid ___…___ ventilation may contribute to migration of the aspirated material and could cause greater obstruction; want to maintain ___ ventilation so you don’t have to use more ___ pressure to maintain their breathing
Avoid non-depolarizing neuromuscular blockers (if you absolutely need to use NMBs, use depolarizing—succs because shorter-acting)…positive pressure ventilation may contribute to migration of the aspirated material and could cause greater obstruction; want to maintain spontaneous ventilation so you don’t have to use more positive pressure to maintain their breathing
Foreign body aspiration—skeletal muscle paralysis may be required for removal if the aspirate object is too ___ to pass through the moving vocal cords; what NMBs should be used if needed?
Too large; use succs or cisatracurium
Foreign body aspiration post-op management—aerosolized ___, ___ to reduce subglottic edema
Aerosolized racemic epi, corticosteroids to reduce subglottic edema
Clinical correlates with tonsillectomy/adenoidectomy—chronic ___ infections, obstructive ___
Chronic upper respiratory infections, obstructive sleep apnea
Anesthetic management of tonsillectomy/adenoidectomy—premedication ___ or ___ midazolam; inhaled induction with ___; intubation—get kid deep with sevo and propofol ___-___ mg/kg or with ___-acting NDNMB
Premedication oral or intranasal midazolam; inhaled induction with sevo; intubation—get kid deep with sevo and propofol 1-2 mg/kg or with short-acting NDNMB
Tonsillectomy/adenoidectomy—typically do not give any ___ for these cases because they are so quick; also don’t want to give ___ to any kids under the age of 14 years d/t risk of undiagnosed neuromuscular disorder/increased risk of ___kalemia
Typically do not give any muscle relaxant for these cases; also don’t want to give succs d/t increased risk of hyperkalemia
If kid has OSA and you are giving pain medication for tonsillectomy/adenoidectomy, cut dose by ___
1/2
Analgesia for tonsillectomy/adenoidectomy—can give MSO4 ___ mg/kg or fentanyl ___-___ mcg/kg
MSO4 0.1 mg/kg or fentanyl 1-2 mcg/kg
Steroids for tonsillectomy/adenoidectomy—dexamethasone ___-___ mg/kg; usually give ___-___ mg dose
0.5-1 mg/kg; usually give 12-20 mg dose
Emergence for tonsillectomy/adenoidectomy—extubate child when they are ___; want to make sure the back of the mouth is ___ and that any bleeding has ___
Fully awake; want to make sure the back of the mouth is dry and that any bleeding has stopped
Post-tonsillectomy bleeding = bleeding that continues or recurs after tonsillectomy and requires ___ intervention
Surgical intervention (packing or suturing)
Early post-tonsillectomy bleeding = within the first ___; 99% occur within the first ___ hours post-op
Within the first 24 hours; 99% occur within the first 6 hours post-op
Secondary/delayed post-tonsillectomy bleeding = ___ hours up to ___-___ weeks post-op; peak = day ___
24 hours up to 2-3 weeks post-op; peak = day 7 post-op
Prevention of post-tonsillectomy bleeding—avoid surgery during/immediately after acute ___ and ___—wait to do surgery until ___ weeks post-infection; avoid blind, vigorous ___; avoid use of ___
Avoid surgery during/immediately after acute inflammation and infection—wait to do surgery until 6 weeks post-infection; avoid blind, vigorous suctioning; avoid use of NSAIDs
Symptoms of post-tonsillectomy bleed—if child is at home, may go unrecognized for days and child will be much sicker and very unstable—T/F?
True
Clinical presentation of post-tonsillectomy bleed (if severe)—___volemia; ___emia; ___tation; ___; stomach full of ___; frequent ___; active ___ and poor visualization of the ___
Hypovolemia; anemia; agitation; shock; stomach full of blood; frequent swallowing; active bleeding and poor visualization of the glottis
Treat post-tonsillectomy bleed as a ___
Full stomach—stomach full of blood!
Post-tonsillectomy bleeding—need to know ___ and ___ (how dehydrated is the patient?)
Hemoglobin and urine specific gravity—normal is 1.010-1.015
Post-tonsillectomy bleed take back to OR—induction—treat as a ___ stomach, perform ___ with ___ pressure; have ___ suctions, ___ blades/handles, experienced assistant
Treat as a full stomach, perform RSI with cricoid pressure; have 2 suctions, 2 blades/handles, experienced assistant
Post-tonsillectomy bleed—emergence—suction ___ with OGT at the end of the case (usually ENT will place OGT); ___ extubation
Suction stomach with OGT; awake extubation
___ = occlusion of one or both posterior nares
Choanal atresia
Since neonates are obligatory nose breathers, bilateral choanal atresia causes suffocation if the mouth is not kept open with an oral airway or large rubber nipple secured in the mouth—T/F?
True
Unilateral atresia may go undiagnosed for months or years; it is eventually diagnosed d/t the presence of intractable unilateral nasal ___
Drainage
Choanal atresia—surgical correction or tracheostomy must be performed within the first few days of life—T/F?
True
Anesthetic management of choanal atresia—___ intubation with Oral RAE tube
Awake
Choanal atresia—emergence—patient should be ___ for extubation
Wide awake
Choanal atresia post-op—partial or intermittent airway obstruction may persist for some time, so the infant must be observed with appropriate monitoring until airway patency is assured; patient will usually stay in the hospital for monitoring for at least 24 hours—T/F?
True
