Mod V: Pediatric Airway management Flashcards
Pediatric Airway management
Airway management can prove particularly challenging in the pediatric patient due to:
Physiological and anatomical issues
Physiologic Issues
Physiologic issues that make Airway management particularly challenging in the pediatric patient include:
Low FRC
High O2 consumption
High “alveolar/FRC” ratio
These all lead to RAPID DESATURATION!!!
Physiologic Issues
Why are infants and neonates dependent on HR for CO?
Noncompliant ventricles
Physiologic Issues
Which CV complication would Hypoxia lead to very quickly in peds?
CV collapse
Hypoxia => Bradycarddia => CV collapse
Physiologic Issues
Why is Airway patency “HIGHEST PRIORITY” in peds vs. adults?
Time from apnea to CV collapse is much shorter in peds vs. adults
Physiologic Issues
What dose of Atropine is often administered during induction in peds?
Atropine
Induction dose: 0.02 mg/kg
Physiologic Issues
Why is Atropine (0.02 mg/kg) often administered during induction in peds?
To preempt Bradycardia
Remember infants and neonates are dependent on HR for CO due to noncompliant ventricles
Also Hypoxia => Bradycarddia => CV collapse
Pediatric Airway Equipment
Preparation for airway management must be complete. What does it include?
Appropriate sized equipment…
must be immediately available
(Laryngoscopes, oral airways, LMA’s, ETT)
Several airways of each type…
should be prepared to allow quick adjustment should this be required
Pediatric Airway Equipment - Laryngoscopes
How do peds Laryngoscopes handle differ from adult’s ones?
Narrower
Less cumbersome
Lighter weight
More natural feel with smaller blade
You can put the smaller blade on the big handle, just feels akward!!!
Pediatric Airway Equipment - Laryngoscopes
Blades Assortment sizes:
0, 1, 2
Pediatric Airway Equipment - Laryngoscopes
Blades Styles:
MAC vs. Miller
Wis-Hippel or Robertshaw (Wide flange)
Engages tongue left - Facilitates ET passage
Pediatric Airway Equipment - Laryngoscopes
Curved Laryngoscope blade types. During laryngoscopy, the tip or beak of the blade is compressed into the angle formed by the base of the tongue and the epiglottis, indirectly raising the epiglottis:
Macintosh or Mac Blade
Pediatric Airway Equipment - Laryngoscopes
Straight laryngoscope blade is traditionally recommended for intubation in infants, due to the large size and flexibility of the infant epiglottis, since it allow to lift the epiglottis directly:
Miller Blade
Pediatric Airway Equipment - Laryngoscopes
Straight blade with a wider flange more like the Mac blade; this blade is also known as:
Wis Hipple Blades
Pediatric Airway Equipment - Laryngoscopes
Blade designed for neonatal and infant use, this blade features a wide flange and a gentle shallow curvature of the blade to lift the epiglottis indirectly in a similar way to the Macintosh blades
Robertshaw Blade
Pediatric Airway Equipment - Laryngoscopes
Recommended Mac Blade size for Ages 1-2 y/o
MAC 1
(9 cm)
Pediatric Airway Equipment - Laryngoscopes
Recommended Mac Blade for Ages 3-5 y/o
MAC 2
(11cm)
Pediatric Airway Equipment - Laryngoscopes
Recommended Miller Blade size for Neonate/Infant:
Miller 0
Pediatric Airway Equipment - Laryngoscopes
Recommended Miller Blade size for Ages 1-2 y/o:
Miller 1
Pediatric Airway Equipment - Laryngoscopes
Recommended Miller Blade size for Ages 2-6 y/o:
Miller 2
Pediatric Airway Equipment - Laryngoscopes
Recommended Wis-Hippel Blade size for Ages 1-2 y/o:
Wis-Hipple 1
Pediatric Airway Equipment - Laryngoscopes
Recommended Wis-Hippel Blade size for Ages 3-4 y/o:
Wis-Hipple 1.5
Pediatric Airway Equipment - Laryngoscopes
Recommended Mac Blade size for Ages > 8 y/o
MAC 3
Pediatric Airway Equipment - Laryngoscopes
Recommended Miller Blade size for Ages > 8 y/o:
Miller 2-3
Pediatric Airway Equipment - Laryngoscopes
Recommended blade (curve vs straight) for < 2 y/o
Straight
(Recommended for < 2 y/o)
Pediatric Airway Equipment - Laryngoscopes
Recommended blade (curve vs straight) for > 5 y/o
Curved
(Recommended for > 5 y/o)
Pediatric Airway Equipment - Endotracheal Tubes
ET tube size for Preterm (< 1000g):
2.5 mm
Pediatric Airway Equipment - Endotracheal Tubes
ET tube size for Preterm (> 1000 gm)
3.0 mm
Pediatric Airway Equipment - Endotracheal Tubes
ET tube size for Neonate to 3 mos.:
3.0 mm
Pediatric Airway Equipment - Endotracheal Tubes
ET tube size for 3-9 mos.:
3.5 mm
Pediatric Airway Equipment - Endotracheal Tubes
ET tube size for 9-18 mos.:
4.0 mm
Pediatric Airway Equipment - Endotracheal Tubes
Formula for calculating ET tube size for ≥ 2 y/o:
(Age/4) + 4 = xx mm ET tube
Pediatric Airway Equipment - Endotracheal Tubes
Diameter of which body part can be used to estimate ET tube size in peds?
Pinky diameter
Pediatric Airway Equipment - Endotracheal Tubes
What test can we perform to confirm that we have the appropriate ETT size?
Airway Leak Test
Test airway pressure at which gas audibly escapes around ETT
Appropriate ETT size must allow for leak @ 15-25 cm H20 pressure
The leak test will minimize the likelihood that an excessively large tube has been inserted. Correct tube size and appropriate cuff inflation is confirmed by easy passage into the larynx and the development of a gas leak at 15 to 25 cm H2O pressure.
Pediatric Airway Equipment - Endotracheal Tubes
What conclusion could you draw regarding your ET tube size, if it takes > 25 cm H20 of pressure to get a leak on the Airway Leak Test?
ETT too large
This could lead to Tracheal edema
Which could lead to postextubation croup
No leak indicates an oversized tube or overinflated cuff that should be replaced or deflated to prevent postoperative edema.
Pediatric Airway Equipment - Endotracheal Tubes
What conclusion could you draw regarding your ET tube size, if it takes < 15 cm H20 of pressure to get a leak on the Airway Leak Test?
ETT too small
ETT too small or you need more air in your cuff
A leak that large could lead to:
Inadequate ventilation
Aspiration
OR pollution
An excessive leak may preclude adequate ventilation and contaminate the operating room with anesthetic gases
Pediatric Airway Equipment - Endotracheal Tubes
What other size ET tubes should you Always have available in the addition to the appropriate or calculated size?
Half size smaller ETT and
Half size larger ETT
Pediatric Airway Equipment - Endotracheal Tubes
What’s the appropriate ETT depth for peds < 1 year of age?
< 4 kg = 6 + Wt (kg)
> 4 kg = 10 cm @ lip
Pediatric Airway Equipment - Endotracheal Tubes
How is the appropriate ETT depth calculate for peds > 1 year of age?
12 + (Age ÷ 2)
or
3X’s ID
Pediatric Airway Equipment - Endotracheal Tubes
What’s the appropriate 4.0 ETT depth for peds > 1 year of age?
3X’s ID = 3 x 4.0 = 12cm
4.0 ETT depth = 12 cm
Pediatric Airway Equipment - Endotracheal Tubes
How can you ensure that the tip of the ETT tube is just proximal to the carina?
You want the Double black line on the ETT tube just past the Vocal Cords
When double black line on the uncuffed ET tube passes through cords, tip is proximal to carina
Pediatric Airway Equipment - Endotracheal Tubes
What are the steps of the most precise method to estimate appropriate ET tube depth?
Intubate the pt
Advance ETT until BS lost over L axilla (R mainstem)
Note length at carina & pull back while bagging the pt until you hear bilateral BS to mid trachea
Then, you can say that the tube is as deep as possible while maintaining bilateral BS
Pediatric Airway Equipment - Endotracheal Tubes
What’s the normal distance between the vocal cords & the carina?
4-5 cm
Pediatric Airway Equipment - Endotracheal Tubes
Where should the inflated cuff be palpated on the patient if properly positionned?
Suprasternal notch
Pediatric Airway Equipment - Endotracheal Tubes
What distance should be added to Nasal RAE tube for appropriate depth?
2-3 cm
Pediatric Airway Equipment - Face Masks
What are the different types of Face masks?
Bubble Masks
Rendell-Baker-Soucek Masks
Pediatric Airway Equipment - Face Masks
What are some characteristics of Bubble Masks?
↑ Dead-space
Pneumatic cushion
Easier to maintain airtight fit
Effective seal for PPV
Pediatric Airway Equipment - Face Masks
What are some characteristics of Rendell-Baker-Soucek Masks?
↓Dead-space
Low profile
Difficult to maintain airtight fit
Pediatric Airway Equipment - Face Masks
Correct Fit of the Rendell-Baker-Soucek Masks?
Apex = bridge of nose
Base = crease of lower lip/chip
Pediatric Airway Equipment - Face Masks
Which face is apppropriate if you are concerned about increased deadspace?
Rendell-Baker-Soucek Masks
↓Dead-space
Pediatric Airway Equipment - Face Masks
Which face mask is easier to maintain airtight fit?
Bubble Masks
Pediatric Airway Equipment - Face Masks
Which face mask provides effective seal for PPV?
Bubble Masks
It’s nearly impossible to generate PPV with Rendell-Baker-Soucek Masks
This is why they have fallen hugely out of favor and have been replaced by Bubble Masks
Pediatric Airway - Mask Ventilation
Why is Mask Ventilation challenging in the child < 4 y/o?
Smaller face
Large tongue
Set up for Upper airway obstruction
Pediatric Airway - Mask Ventilation
Which actions or condition may facilitate Upper airway obstruction?
Provider’s fingers may compress soft tissues of the neck
Excessive neck extension
Laryngomalacia = supraglottic tracheal collapse with inspiration
Pediatric Airway - Mask Ventilation
Supraglottic tracheal collapse with inspiration is also known as:
Laryngomalacia
This is a congenital softening of the tissues of the larynx (voice box) above the vocal cords. This is the most common cause of noisy breathing in infancy. The laryngeal structure is malformed and floppy, causing the tissues to fall over the airway opening and partially block it
Pediatric Airway - Mask Ventilation
What’s the proper placement of face mask (FM) and fingers for effective Mask ventilation technique?
Place FM over nose/mouth
Forefinger/thumb over FM
Middle-finger on boney prominence of mandible
Pediatric Airway - Mask Ventilation
How is Manual Airway opening performed for mask ventilation?
Chin lift
Jaw thrust
Apply CPAP (not to exceed 15 cmH2O)
Pediatric Airway - Mask Ventilation
PPV or CPAP for mask ventilation is not to exceed which pressure value?
15 cmH2O
Pediatric Airway - Mask Ventilation
Failed manual opening of the airway for mask ventilation should be replaced with which alternatives?
Oral airway
Nasal airway
Pediatric Airway - Nasal Airways
As with adults, Nasal Airways are better tolerated in awake pts. Why are Nasal Airways not frequently used w/ peds?
Most children have Adenoidal hypertrophy from 2-6 y/o
Could disrupt that tissue and cause Bleeding
Which could lead to a laryngospasm and _other problem_s
Small internal diameter of nasal airways could ↑ work of breathing according to Poiseuille’s law
Pediatric Airway - Nasal Airways
How to properly size a nasal airway?
Flange at tip of nose
Distal tip at angle of mandible
Pediatric Airway - Oral Airways
T/F: Oral airways are poorly tolerated in awake or slightly anesthetized pts.
True
Pediatric Airway - Oral Airways
How is Proper sizing of oral airway performed?
Flange at lip
Distal tip at angle of mandible
Pediatric Airway - Oral Airways
Proper sizing of oral airway is important. An oral airway that is Too small will:
Push tongue back
Pediatric Airway - Oral Airways
Proper sizing of oral airway is important. An oral airway that is Too large will:
Obstruct laryngeal outlet
Pediatric Airway - Oral Airways
Oral Airways size for Preterm:
[000/00]
3.5- 4.5 cm
Pediatric Airway - Oral Airways
Oral Airways size for < 3mos:
[0]
5.5 cm
Pediatric Airway - Oral Airways
Oral Airways size for 3-12mos:
[1]
6.0 cm
Pediatric Airway - Oral Airways
Oral Airways size for 1-5 y/o:
[2]
7.0 cm
Pediatric Airway - Oral Airways
Oral Airways size for > 5 y/o:
[3]
8.0 cm
Pediatric Airway - Laryngeal Mask
LMA considerations in peds:
More rigid in peds
Suitable for short procedures
Low ventilatory resistance
Use if conventional mask difficult
Not recommended for PPV
Contraindicated in pt at risk for gastric aspiration
