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8361 Exam 2 > Mod V: Pediatric Airway management > Flashcards

Mod V: Pediatric Airway management Flashcards

1
Q

Pediatric Airway management

Airway management can prove particularly challenging in the pediatric patient due to:

A

Physiological and anatomical issues

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2
Q

Physiologic Issues

Physiologic issues that make Airway management particularly challenging in the pediatric patient include:

A

Low FRC

High O2 consumption

High “alveolar/FRC” ratio

These all lead to RAPID DESATURATION!!!

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3
Q

Physiologic Issues

Why are infants and neonates dependent on HR for CO?

A

Noncompliant ventricles

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4
Q

Physiologic Issues

Which CV complication would Hypoxia lead to very quickly in peds?

A

CV collapse

Hypoxia => Bradycarddia => CV collapse

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5
Q

Physiologic Issues

Why is Airway patency “HIGHEST PRIORITY” in peds vs. adults?

A

Time from apnea to CV collapse is much shorter in peds vs. adults

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6
Q

Physiologic Issues

What dose of Atropine is often administered during induction in peds?

A

Atropine

Induction dose: 0.02 mg/kg

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7
Q

Physiologic Issues

Why is Atropine (0.02 mg/kg) often administered during induction in peds?

A

To preempt Bradycardia

Remember infants and neonates are dependent on HR for CO due to noncompliant ventricles

Also Hypoxia => Bradycarddia => CV collapse

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8
Q

Pediatric Airway Equipment

Preparation for airway management must be complete. What does it include?

A

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

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9
Q

Pediatric Airway Equipment - Laryngoscopes

How do peds Laryngoscopes handle differ from adult’s ones?

A

Narrower

Less cumbersome

Lighter weight

More natural feel with smaller blade

You can put the smaller blade on the big handle, just feels akward!!!

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10
Q

Pediatric Airway Equipment - Laryngoscopes

Blades Assortment sizes:

A

0, 1, 2

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11
Q

Pediatric Airway Equipment - Laryngoscopes

Blades Styles:

A

MAC vs. Miller

Wis-Hippel or Robertshaw (Wide flange)

Engages tongue left - Facilitates ET passage

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12
Q

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:

A

Macintosh or Mac Blade

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13
Q

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:

A

Miller Blade

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14
Q

Pediatric Airway Equipment - Laryngoscopes

Straight blade with a wider flange more like the Mac blade; this blade is also known as:

A

Wis Hipple Blades

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15
Q

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

A

Robertshaw Blade

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16
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Mac Blade size for Ages 1-2 y/o

A

MAC 1

(9 cm)

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17
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Mac Blade for Ages 3-5 y/o

A

MAC 2

(11cm)

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18
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Miller Blade size for Neonate/Infant:

A

Miller 0

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19
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Miller Blade size for Ages 1-2 y/o:

A

Miller 1

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20
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Miller Blade size for Ages 2-6 y/o:

A

Miller 2

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21
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Wis-Hippel Blade size for Ages 1-2 y/o:

A

Wis-Hipple 1

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22
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Wis-Hippel Blade size for Ages 3-4 y/o:

A

Wis-Hipple 1.5

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23
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Mac Blade size for Ages > 8 y/o

A

MAC 3

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24
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended Miller Blade size for Ages > 8 y/o:

A

Miller 2-3

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25
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended blade (curve vs straight) for < 2 y/o

A

Straight

(Recommended for < 2 y/o)

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26
Q

Pediatric Airway Equipment - Laryngoscopes

Recommended blade (curve vs straight) for > 5 y/o

A

Curved

(Recommended for > 5 y/o)

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27
Q

Pediatric Airway Equipment - Endotracheal Tubes

ET tube size for Preterm (< 1000g):

A

2.5 mm

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28
Q

Pediatric Airway Equipment - Endotracheal Tubes

ET tube size for Preterm (> 1000 gm)

A

3.0 mm

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29
Q

Pediatric Airway Equipment - Endotracheal Tubes

ET tube size for Neonate to 3 mos.:

A

3.0 mm

30
Q

Pediatric Airway Equipment - Endotracheal Tubes

ET tube size for 3-9 mos.:

A

3.5 mm

31
Q

Pediatric Airway Equipment - Endotracheal Tubes

ET tube size for 9-18 mos.:

A

4.0 mm

32
Q

Pediatric Airway Equipment - Endotracheal Tubes

Formula for calculating ET tube size for ≥ 2 y/o:

A

(Age/4) + 4 = xx mm ET tube

33
Q

Pediatric Airway Equipment - Endotracheal Tubes

Diameter of which body part can be used to estimate ET tube size in peds?

A

Pinky diameter

34
Q

Pediatric Airway Equipment - Endotracheal Tubes

What test can we perform to confirm that we have the appropriate ETT size?

A

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.

35
Q

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?

A

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.

36
Q

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?

A

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

37
Q

Pediatric Airway Equipment - Endotracheal Tubes

What other size ET tubes should you Always have available in the addition to the appropriate or calculated size?

A

Half size smaller ETT and

Half size larger ETT

38
Q

Pediatric Airway Equipment - Endotracheal Tubes

What’s the appropriate ETT depth for peds < 1 year of age?

A

< 4 kg = 6 + Wt (kg)

> 4 kg = 10 cm @ lip

39
Q

Pediatric Airway Equipment - Endotracheal Tubes

How is the appropriate ETT depth calculate for peds > 1 year of age?

A

12 + (Age ÷ 2)

or

3X’s ID

40
Q

Pediatric Airway Equipment - Endotracheal Tubes

What’s the appropriate 4.0 ETT depth for peds > 1 year of age?

A

3X’s ID = 3 x 4.0 = 12cm

4.0 ETT depth = 12 cm

41
Q

Pediatric Airway Equipment - Endotracheal Tubes

How can you ensure that the tip of the ETT tube is just proximal to the carina?

A

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

42
Q

Pediatric Airway Equipment - Endotracheal Tubes

What are the steps of the most precise method to estimate appropriate ET tube depth?

A

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

43
Q

Pediatric Airway Equipment - Endotracheal Tubes

What’s the normal distance between the vocal cords & the carina?

A

4-5 cm

44
Q

Pediatric Airway Equipment - Endotracheal Tubes

Where should the inflated cuff be palpated on the patient if properly positionned?

A

Suprasternal notch

45
Q

Pediatric Airway Equipment - Endotracheal Tubes

What distance should be added to Nasal RAE tube for appropriate depth?

A

2-3 cm

46
Q

Pediatric Airway Equipment - Face Masks

What are the different types of Face masks?

A

Bubble Masks

Rendell-Baker-Soucek Masks

47
Q

Pediatric Airway Equipment - Face Masks

What are some characteristics of Bubble Masks?

A

↑ Dead-space

Pneumatic cushion

Easier to maintain airtight fit

Effective seal for PPV

48
Q

Pediatric Airway Equipment - Face Masks

What are some characteristics of Rendell-Baker-Soucek Masks?

A

↓Dead-space

Low profile

Difficult to maintain airtight fit

49
Q

Pediatric Airway Equipment - Face Masks

Correct Fit of the Rendell-Baker-Soucek Masks?

A

Apex = bridge of nose

Base = crease of lower lip/chip

50
Q

Pediatric Airway Equipment - Face Masks

Which face is apppropriate if you are concerned about increased deadspace?

A

Rendell-Baker-Soucek Masks

↓Dead-space

51
Q

Pediatric Airway Equipment - Face Masks

Which face mask is easier to maintain airtight fit?

A

Bubble Masks

52
Q

Pediatric Airway Equipment - Face Masks

Which face mask provides effective seal for PPV?

A

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

53
Q

Pediatric Airway - Mask Ventilation

Why is Mask Ventilation challenging in the child < 4 y/o?

A

Smaller face

Large tongue

Set up for Upper airway obstruction

54
Q

Pediatric Airway - Mask Ventilation

Which actions or condition may facilitate Upper airway obstruction?

A

Provider’s fingers may compress soft tissues of the neck

Excessive neck extension

Laryngomalacia = supraglottic tracheal collapse with inspiration

55
Q

Pediatric Airway - Mask Ventilation

Supraglottic tracheal collapse with inspiration is also known as:

A

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​

56
Q

Pediatric Airway - Mask Ventilation

What’s the proper placement of face mask (FM) and fingers for effective Mask ventilation technique?

A

Place FM over nose/mouth

Forefinger/thumb over FM

Middle-finger on boney prominence of mandible

57
Q

Pediatric Airway - Mask Ventilation

How is Manual Airway opening performed for mask ventilation?

A

Chin lift

Jaw thrust

Apply CPAP (not to exceed 15 cmH2O)

58
Q

Pediatric Airway - Mask Ventilation

PPV or CPAP for mask ventilation is not to exceed which pressure value?

A

15 cmH2O

59
Q

Pediatric Airway - Mask Ventilation

Failed manual opening of the airway for mask ventilation should be replaced with which alternatives?

A

Oral airway

Nasal airway

60
Q

Pediatric Airway - Nasal Airways

As with adults, Nasal Airways are better tolerated in awake pts. Why are Nasal Airways not frequently used w/ peds?

A

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

61
Q

Pediatric Airway - Nasal Airways

How to properly size a nasal airway?

A

Flange at tip of nose

Distal tip at angle of mandible

62
Q

Pediatric Airway - Oral Airways

T/F: Oral airways are poorly tolerated in awake or slightly anesthetized pts.

A

True

63
Q

Pediatric Airway - Oral Airways

How is Proper sizing of oral airway performed?

A

Flange at lip

Distal tip at angle of mandible

64
Q

Pediatric Airway - Oral Airways

Proper sizing of oral airway is important. An oral airway that is Too small will:

A

Push tongue back

65
Q

Pediatric Airway - Oral Airways

Proper sizing of oral airway is important. An oral airway that is Too large will:

A

Obstruct laryngeal outlet

66
Q

Pediatric Airway - Oral Airways

Oral Airways size for Preterm:

A

[000/00]

3.5- 4.5 cm

67
Q

Pediatric Airway - Oral Airways

Oral Airways size for < 3mos:

A

[0]

5.5 cm

68
Q

Pediatric Airway - Oral Airways

Oral Airways size for 3-12mos:

A

[1]

6.0 cm

69
Q

Pediatric Airway - Oral Airways

Oral Airways size for 1-5 y/o:

A

[2]

7.0 cm

70
Q

Pediatric Airway - Oral Airways

Oral Airways size for > 5 y/o:

A

[3]

8.0 cm

71
Q

Pediatric Airway - Laryngeal Mask

LMA considerations in peds:

A

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

8361 Exam 2 (20 decks)

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