Management of the Challenging Pediatric Airway Flashcards
infants tongue considerations
infants tongue is relatively large in proportion to the rest of the oral cavity. this contributes to easy obstruction of the infants airway. oral airway helps to relieve the obstruction.
infants nasal passages
relatively narrow
infants salivary secretions
pronounced
infants tonsils and adenoids
large
position of larynx in kids
higher (more cephalic) for neonates 2 years of age. (2 years is usually the age where you can switch to a MAC blade)
larynx seems more anterior with a more acute angle
C3-C4 (adult is C4-C5)
a straight laryngoscope blade more effectively lifts tongue from field of view
anatomy of pediatric airway: epiglottis
adults epiglottis is flat and broad with an axis parallel to the trachea
infants epiglottis is narrower, omega shaped and angled away for the axis of the trachea
often obstructs view of the vocal cords and is more difficult to lift
anatomy of pediatric airway: vocal cords
infants vocal cords have a lower (caudad) attachment anteriorly than posteriorly, whereas in the adult the axis of the vocal cords is perpendicular to the trachea
can lead to difficult intubation with the tip of the ETT held up at the anterior portion of the folds
anatomy of pediatric airway: trachea
shorter than adults (infant 4-5cm, adult 10-12cm)
anatomy of pediatric airway: subglottic
narrowest portion of childs larynx is cricoid cartilage (until about 8). in adults it is the glottic opening
when too large of an ETT is inserted, it may pass through the cords, but may become immediately stuck below the cords (subglottic or cricoid ring region)
funnel versus elliptical (football) shaped (anteriors-posterior dimension being greater than the transverse dimension)
a tight fitting ETT that depresses the tracheal mucosa can
cause edema, reduce the luminal diameter and result in post extubation croup
evaluation of the airway includes
mallampati and mandible hx of syndrome/congential anomalies or physical findings missing or loose teeth recent respiratory infections work of breathing snoring/noisy breathing at night baseline SpO2 asthma/smoking global appearance
anatomic feature: prominent occiput (big head)
implications
management
implications: neck flexed in supine position, upper aw obstruction likely, Oral/pharyngeal/laryngeal axes are not lined up, making laryngoscopy more difficult
shoulder roll for infants
anatomic feature: cephalic larynx
implication
management
larynx seems more anterior
entire tongue is in oral cavity, increasing risk of obstruction
managment: lateral approach to laryngoscopy, oral aw to relieve obstruction
anatomical feature: epiglottis angled over vocal cords
implication
management
epiglottis often obstructs view of vocal cords
straight laryngoscope blade in children under 3 years of age
evidence of aw obstruction includes
tracheal tug, paradoxical chest wall movement, absence of movement in ambu breathing bag or capnography tracing.
most frequent mistake is late recognition of upper airway obstruction
evidence of inadequate sedation depth
struggle, breath holding, partial aw obstruction, rapid desaturation
evidence of overly aggressive bag mask ventilation
leads to gastric insufflation, reducing lung volume, increased risk of regurgitation
highest difficult aw predictors include
highest in infant age group, craniofacial abnormalities, congenital cardiac abnormalities
difficult airway may improve with age except in these syndromes
goldenhar and mucopolysaccharidoses the airway becomes difficult with age
mallampati correlates with
cormack-lehane view
when observing childs profile, look for
smaller than normal or recessed mandible, limited mouth opening, prominent dentition, facial asymmetry, cleft palate
syndromes and conditions associated with a difficult airway
goldenhar pierre robin treacher collins apert trisomy 21 juvenile arthritis cleft palate trauma/burrn oral tumors kipper-feil mucopolysacc haridosis
preparation for difficult airway
difficult aw card (laryngoscope blades, LMA’s, tracheal tubes, oral and nasal airways, fiberoptic and video laryngoscope instruments)
IV access
experienced assistance
sedation options
plans A, B, C
communication with otolaryngologist and anesthesia providers in advance
induction strategies include
maintain spontaneous respirations whenever possible
delay PPV and NDMB’s especially in mediastinal tumors, epiglottis, foreign body, limited mouth opening
a nasopharyngeal airway or small ETT inserted in nasopharynx can act as oxygen conduit during intubation attempts
cautious titration with combination of propofol, ketamine, dexmedetomidine, midazolam
direct laryngoscopy with straight blade
will often yield best view in micrognathic/retrognathic patients
insert on extreme right
may be helpful to have assistant pull back right corner of childs mouth
styletted ETT (careful to not advance through vocal cords to avoid damage to trachea with stiff end of stylet)
supraglottic airways when obstruction is beyond glottis
not as useful. requirement of high ventilation pressure and those at risk for pulmonary aspiration
supraglottic airways and FOI
useful as conduit for FOI. often easier to perform once ventilation has been established as successful and then patient is sedated or paralyzed
how to utilize video laryngoscope
since children will desaturate more quickly with apnea, consider inserting styletted ETT into the right of the mouth towards hypo pharynx prior to video laryngoscope insertion. stylet in the shape of the blade. insertion technique is midline. may also be used with flexible FOI
flexible fiberoptic scope how to utilizr
adequate oxygenation throughout
hold the scope at the level where its tip will be at the vocal cords (roughly the angle of the mandible). index finger and thumb grasp the scope at the point where the fingers touch the patient lips/nose
direct the scope midline with anterior flexion at the tip
the unanticipated difficult airway and if bag mask ventilation is easy or the patient is spontaneously breathing
reverse any sedation/muscle relaxation if possible and awaken the child. do not repeat identical attempts at direct laryngoscopy. consider an LMA to temporize, improve oxygenation, and free up providers hands
the unanticipated difficult airway and if bag mask ventilation is not adequate
immediately request expert help including otolaryngologist, anesthesia provider, ECMO deployment
2 hand bag mask attempt->LMA insertion->emergency invasive airway access (cricothyroidotomy/rigid bronchoscopy/surgical tracheostomy)
LMA for free hands+call for help
cricothyroidotomy supplies
syringe half filled with saline
IV catheter
15mm adapter from ETT
difficult airway, unexpected- sequence of events
increase O2 to 100%, call for help, surgical aw expert and cart, bronchoscopy and tracheostomy kit
if unable to mask ventilate, ask for 2 handed assistance and insert OPA/NPA, if unsuccessful, insert supraglottic aw, decompress stomach with OGT, consider reversing with sugammadex
if able to re establish spontaneous ventilation, consider awakening patient
agter two attempts, change provider and consider alternative approaches
if macroglossie, or mediastinal mass, consider prone or lateral position
if still unable to ventilate: younger children: emergency non invasive airway such as rigid bronchoscopy.
in older children: jet ventilation or emergenvy/invasive surgical airway such as cricothyroitomy or tracheostomy
alternative approaches for intubation
different blade reposition head different provider video laryngoscope bougie intubating LMA fiberoptic scope intubating stylet blind oral blind nasal
