Lecture 2 (Part 2)-Respiratory A&P In Infants And Children

Question 1

Pediatric airway anatomy—___ (small/large) head, ___ (long/short) neck, ___ (small/large) tongue which can easily obstruct airway

Answer 1

Large head, short neck, large tongue

Question 2

Deciduous teeth erupt at __ months of age; begin shedding between ___-___ years of age

Answer 2

Erupt at 6 months of age; begin shedding between 6-8 years of age

Question 3

Pediatric airway—epiglottis is ___ (wider/narrower), ___ (shorter/longer), and at a more ___ angle from the trachea, making it more difficult to lift

Answer 3

Epiglottis is narrower, longer, and at a more acute angle from the trachea, making it more difficult to lift

Question 4

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

Answer 4

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

Question 5

Peds—tongue is ___ (smaller/larger) in proportion to the oral cavity than in the adult

Answer 5

Larger

Question 6

Peds—larynx is ___ (lower/higher) in the neck in neonates/children than in adults

Answer 6

Higher

Neonates—C2

Children—C3-C4

Adults—C5-C6

Question 7

Cricoid is more ___ shaped in infants

Answer 7

Conically

Question 8

Narrowest portion of the pediatric airway is at the ___; in adults, it’s at the level of the ___

Answer 8

Cricoid ring; level of the vocal cords

Question 9

Trachea in children is deviated ___ (anteriorly/posteriorly) and ___ (upward/downward); it becomes anatomically similar to adults between ___ and ___ years of age

Answer 9

Posteriorly and downward; becomes anatomically similar to adults between 8 and 10 years of age

Question 10

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

Answer 10

Relatively large; optimal intubating position is with shoulder roll to prevent neck flexion in the supine position

Question 11

Pediatric larynx located at ___-___

Answer 11

C3-C4

Question 12

Adult larynx located at ___-___

Answer 12

C4-C5

Question 13

Length of the trachea (vocal cords to carina) in neonates and children up to one year of age is ___-___ cm or ___-___ inches

Answer 13

5-9 cm or 2-2.5 inches

Question 14

Do not ___ the ETT once you go through the vocal cords

Answer 14

Bury

Question 15

If the ETT does not slide in easily, do NOT ___…you need to ___ the ETT

Answer 15

Force it…you need to downsize the ETT

Question 16

___-___ cm H2O should leak

Answer 16

15-25 cm H2O

Question 17

Infant epiglottis is ___ shaped and angled ___ from the axis of the trachea

Answer 17

Omega shaped and angled away from the axis of the trachea

Question 18

It is easier to lift an infant’s epiglottis with a laryngoscopic blade—T/F?

Answer 18

False—it is more difficult to lift an infant’s epiglottis

Question 19

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

Answer 19

LARGE increase in resistance to flow (Poiseuille’s Law)

Question 20

Infants are obligate ___ breathers until 3-5 months of age because the major source of resistance to airflow is the lower airways

Answer 20

Nasal

Question 21

Occlusion of the nares can cause complete airway obstruction—T/F?

Answer 21

True—when placing mask on child, be careful not to occlude the nares

Question 22

Anesthesia ___ (increases/decreases) FRC by causing peripheral airway collapse and impaired intercostal and diaphragm activity

Answer 22

Decreases FRC

Question 23

FRC in infant is ___-___ ml/kg, adult is ___ ml/kg

Answer 23

Infant is 27-30 ml/kg, adult is 30 ml/kg

Question 24

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!!!

Answer 24

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!!!

Question 25

How to calculate ETT size for pediatrics =

Answer 25

(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

Question 26

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

Answer 26

15-25 cm H2O

Question 27

If you don’t have a leak up to 40 cm H2O, you need to ___ the ETT

Answer 27

Change the ETT

Question 28

Always prepare to have your calculated tube size and ___ size smaller

Answer 28

1/2 size smaller—in case you meet resistance

Question 29

Physical exam—assess child’s work of breathing—if nasal ___ or ___ are present, cancel the surgery (unless it’s emergent)

Answer 29

Nasal flaring or retractions

Question 30

Physical exam—presence of upper respiratory infection within the past 2-6 weeks = significant risk of ___

Answer 30

Bronchospasm

Question 31

If patient is wheezing, has green nasal drainage, and fever, ___ surgery

Answer 31

Postpone

Question 32

Common airway problems—laryngospasm—caused by stimulation of the ___ laryngeal nerve, not the ___ laryngeal nerve; caused by stimulation in stage ___ of anesthesia

Answer 32

Superior laryngeal nerve, not the recurrent laryngeal nerve; caused by stimulation in stage 2 of anesthesia

Question 33

Common airway problems—laryngospasm—caused by contraction of the ___ muscles of the larynx (___ cricoarytenoids, ___arytenoids, ___arytenoids)

Answer 33

Caused by contraction of the adductor muscles of the larynx (lateral cricoarytenoids, thyroarytenoids, cricoarytenoids)

Question 34

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)

Answer 34

Inhalation of volatile agents; excessive secretions in the airway; presence of URI; manipulation of the airway

Question 35

Treatment of laryngospasm—first line = give ___ and ___ pressure at ___ cm H2O

Answer 35

Give propofol and positive pressure at 40 cm H2O

Question 36

If propofol and positive pressure don’t break laryngospasm, give ___ + ___

Answer 36

Succinylcholine 0.4 mg/kg IV; 4 mg/kg IM + atropine 20 mcg/kg IM/IV

Question 37

It is okay to give 40 cm H2O positive pressure through an LMA to break laryngospasm—T/F?

Answer 37

False— > 30 cm H2O breaks the seal of the LMA…do not give > 30…can remove LMA and give 40 cm H2O via mask

Question 38

Post-intubation laryngeal edema is a potential complication of intubation in all children but the incidence is greatest in children ages ___-___

Answer 38

1-4

Question 39

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

Answer 39

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!!!

Question 40

Treatment of post-intubation laryngeal edema = ___ of inspired gases; aerosolized ___; re-___; ___ (surgical airway)

Answer 40

Humidification of inspired gases; aerosolized racemic epinephrine (0.5 ml of 2.25% solution in 2-3 ml saline); re-intubation; tracheostomy

Question 41

Epiglottitis—etiology = haemophilus influenzae type ___

Answer 41

B

Question 42

Epiglottitis occurs in children ___-___ years of age

Answer 42

3-6 years of age

Question 43

Epiglottitis—rapid progression of symptoms, over ___

Answer 43

< 24 hours

Question 44

Symptoms of epiglottitis = ___phagia, ___phonia, leaning over and profusely ___, ___ stridor, respiratory ___

Answer 44

Dysphagia, dysphonia, leaning over and profusely drooling, inspiratory stridor, respiratory distress

Question 45

Epiglottitis typically presents with high fever, > ___ degrees C

Answer 45

> 39

Question 46

Treatment of epiglottitis = ___; urgent intubation of the trachea under ___ anesthesia—need to be in the ___; ___, ___; fluids

Answer 46

Oxygen; urgent intubation of the trachea under general anesthesia—need to be in the OR; antibiotics, antipyretics; fluids

Question 47

Anesthetic management of epiglottitis—do nothing to ___ or ___ the child

Answer 47

Do nothing to upset or agitate the child…don’t want them crying and irritating the tissue even more

Question 48

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

Answer 48

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

Question 49

Anesthetic management of epiglottitis—achieve stage ___ of anesthesia to prevent ___

Answer 49

Achieve stage 3 of anesthesia to prevent laryngospasm

Question 50

Anesthetic management of epiglottitis—___ has to be present; they need to be available in case a surgical airway (i.e.: tracheostomy) is necessary

Answer 50

ENT

Question 51

Anesthetic management of epiglottitis—place the child supine, intubate the trachea with a small ETT a ___ smaller than you typically would use

Answer 51

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

Question 52

Anesthetic implications for epiglottitis—inflammation of the airway may enhance irritability and increase the potential for ___, ___, and ___

Answer 52

Coughing, breathholding, and laryngospasm

Question 53

Anesthetic implications for epiglottitis—CV depressant effects of inhalation agents may be magnified r/t ___

Answer 53

Hypovolemia—child will be dehydrated d/t difficulty swallowing

Question 54

Anesthetic implications for epiglottitis—rigid ventilating ___ and ___ equipment must be available

Answer 54

Rigid ventilating bronchoscope and surgical airway equipment…child may need an urgent trach/cric, depending on how bad the swelling is

Question 55

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

Answer 55

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

Question 56

Laryngotracheobronchitis is aka ___, ___ infection

Answer 56

Croup, subglottic infection

Question 57

Croup accounts for ___% of infectious upper airway obstruction in children

Answer 57

90%

Question 58

Etiology of croup—___ virus type 1 and 2, influenzae ___, respiratory ___ virus

Answer 58

Parainfluenzae virus type 1 and 2, influenzae type A, respiratory syncytial virus (RSV)

Question 59

Croup occurs in children < ___ years of age

Answer 59

< 2 years of age

Question 60

Epiglottitis occurs in children ___-___ years of age

Answer 60

3-6 years

Question 61

Pathology of croup—mucosal and submucosal edema within the ___ ring, ___ (increased/decreased) luminal size

Answer 61

Cricoid ring, decreased luminal size

Question 62

Croup has a ___ onset and progression of symptoms, over ___-___ hours

Answer 62

Gradual onset and progression of symptoms, over 24-72 hours

Question 63

Symptoms of croup—history of ___ progressing to ___ cry or ___ cough; low grade fever < ___ degrees C

Answer 63

History of URI progressing to hoarse cry or barking cough; low grade fever < 39 degrees C

Question 64

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

Answer 64

O2 with cool aqueous mist; aerosolized racemic epi; albuterol; corticosteroids; antipyretics; intubation of the trachea is rare unless exhaustion occurs

Question 65

Foreign body aspiration—most frequent site of obstruction is ___

Answer 65

Right mainstem

Question 66

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

Answer 66

Right = 15 degrees, left = 45 degrees—right is the pathway of least resistance

Question 67

Signs of foreign body aspiration = ___, ___, decreased air entry into ___ lung, ___ infection, ___

Answer 67

Cough, wheezing, decreased air entry into affected lung, upper respiratory infection, pneumonia

Question 68

Treatment of foreign body aspiration—___ or ___ removal; best to remove object within ___ hours

Answer 68

Laryngoscopic or endoscopic removal; best to remove object within 24 hours

Question 69

Anesthetic management of foreign body aspiration—induction technique depends on the severity of airway ___

Answer 69

Obstruction

Question 70

Anesthetic management of foreign body aspiration—with airway obstruction, induce with inhalation of ___ agent and ___ while maintaining ___ ventilation

Answer 70

Induce with inhalation of volatile agent and oxygen while maintaining spontaneous ventilation

Question 71

Anesthetic management of foreign body aspiration—without airway obstruction, ___ induction with standard agents

Answer 71

IV

Question 72

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)

Answer 72

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)

Question 73

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

Answer 73

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

Question 74

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?

Answer 74

Too large; use succs or cisatracurium

Question 75

Foreign body aspiration post-op management—aerosolized ___, ___ to reduce subglottic edema

Answer 75

Aerosolized racemic epi, corticosteroids to reduce subglottic edema

Question 76

Clinical correlates with tonsillectomy/adenoidectomy—chronic ___ infections, obstructive ___

Answer 76

Chronic upper respiratory infections, obstructive sleep apnea

Question 77

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

Answer 77

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

Question 78

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

Answer 78

Typically do not give any muscle relaxant for these cases; also don’t want to give succs d/t increased risk of hyperkalemia

Question 79

If kid has OSA and you are giving pain medication for tonsillectomy/adenoidectomy, cut dose by ___

Answer 79

1/2

Question 80

Analgesia for tonsillectomy/adenoidectomy—can give MSO4 ___ mg/kg or fentanyl ___-___ mcg/kg

Answer 80

MSO4 0.1 mg/kg or fentanyl 1-2 mcg/kg

Question 81

Steroids for tonsillectomy/adenoidectomy—dexamethasone ___-___ mg/kg; usually give ___-___ mg dose

Answer 81

0.5-1 mg/kg; usually give 12-20 mg dose

Question 82

Emergence for tonsillectomy/adenoidectomy—extubate child when they are ___; want to make sure the back of the mouth is ___ and that any bleeding has ___

Answer 82

Fully awake; want to make sure the back of the mouth is dry and that any bleeding has stopped

Question 83

Post-tonsillectomy bleeding = bleeding that continues or recurs after tonsillectomy and requires ___ intervention

Answer 83

Surgical intervention (packing or suturing)

Question 84

Early post-tonsillectomy bleeding = within the first ___; 99% occur within the first ___ hours post-op

Answer 84

Within the first 24 hours; 99% occur within the first 6 hours post-op

Question 85

Secondary/delayed post-tonsillectomy bleeding = ___ hours up to ___-___ weeks post-op; peak = day ___

Answer 85

24 hours up to 2-3 weeks post-op; peak = day 7 post-op

Question 86

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 ___

Answer 86

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

Question 87

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?

Answer 87

True

Question 88

Clinical presentation of post-tonsillectomy bleed (if severe)—___volemia; ___emia; ___tation; ___; stomach full of ___; frequent ___; active ___ and poor visualization of the ___

Answer 88

Hypovolemia; anemia; agitation; shock; stomach full of blood; frequent swallowing; active bleeding and poor visualization of the glottis

Question 89

Treat post-tonsillectomy bleed as a ___

Answer 89

Full stomach—stomach full of blood!

Question 90

Post-tonsillectomy bleeding—need to know ___ and ___ (how dehydrated is the patient?)

Answer 90

Hemoglobin and urine specific gravity—normal is 1.010-1.015

Question 91

Post-tonsillectomy bleed take back to OR—induction—treat as a ___ stomach, perform ___ with ___ pressure; have ___ suctions, ___ blades/handles, experienced assistant

Answer 91

Treat as a full stomach, perform RSI with cricoid pressure; have 2 suctions, 2 blades/handles, experienced assistant

Question 92

Post-tonsillectomy bleed—emergence—suction ___ with OGT at the end of the case (usually ENT will place OGT); ___ extubation

Answer 92

Suction stomach with OGT; awake extubation

Question 93

___ = occlusion of one or both posterior nares

Answer 93

Choanal atresia

Question 94

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?

Answer 94

True

Question 95

Unilateral atresia may go undiagnosed for months or years; it is eventually diagnosed d/t the presence of intractable unilateral nasal ___

Answer 95

Drainage

Question 96

Choanal atresia—surgical correction or tracheostomy must be performed within the first few days of life—T/F?

Answer 96

True

Question 97

Anesthetic management of choanal atresia—___ intubation with Oral RAE tube

Answer 97

Awake

Question 98

Choanal atresia—emergence—patient should be ___ for extubation

Answer 98

Wide awake

Question 99

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?

Answer 99

True