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Ped. Respiratory Anatomy And Physiology Flashcards

1
Q

What is different in children vs adults regarding the tongue?

A

Tongue:

- larger in proportion to oral cavity than in adult

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2
Q

What is different in children vs adults regarding the epiglottis?

A

Epiglottis

  • narrower, shorter at level of 1st vertebrae and overlaps soft palate
  • Ω shaped
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3
Q

What is different in children vs adults regarding the larynx?

A

Larynx:

  • higher in the neck, C2 in neonate
  • C 3-4 in children (C5-6 in adults)
  • angle between base of tongue and glottis opening is more acute
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4
Q

What is different in children vs adults regarding the cricoid?

A

Cricoid:

- conically shaped, narrowest portion is at cricoid ring (adults is vocal cords)

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5
Q

What is different in children vs adults regarding the trachea?

A
  • Deviated posteriorly and downward
  • Is similar to adult around 8-10 years
    —> length of trachea (vocal cords to carina) in neonates and children up to 1 year is 5-9 cm or 2-2.5 inches
    ** do not bury ETT once through the vocal cords **
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6
Q

What is different in children vs adults regarding the head?

A
  • Occipital is larger
  • optimal incubating position is with a shoulder roll to prevent neck flexion while supine
    —> extreme neck extension causes obstruction- want head parallel with the ceiling
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7
Q

What implications does the small airway size have?

A

A small decrease in airway size (edema/trauma) results in a huge increase in resistance to flow

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8
Q

T/F Infants are obligate nasal breathers until 3-5 months because major source of resistance to airflow is in the lower airways.

A

True

Overcoming resistance of nares takes only 25% of work of breathing in infants (60% in adults)

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9
Q

Occluding an infants nares = ____________ airway obstruction.

A

Complete

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10
Q

1 mm edema decreases crossectional area by ____, and increases resistance ______ in laminar flow.

A

75%
16 times
(Will increase resistance 32 times in turbulent flow)

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11
Q

Under 6 months of age the primarily rely on what type of breathing?

A

Diaphragmatic

Intercostals contribute 20-40% to ventilation

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12
Q

Under 6 months, the thorax is weak and unstable with a smaller % of which type of diaphragmatic fibers?

A

Type I fatigue resistant

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13
Q

In infants FRC is small but ______ __________.

A

Not functional

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14
Q

How do you calculate the ETT size for a child?

A

(Age in years + 16)/4= internal diameter in mm

  • if newborn use 3.0 tube
  • if <6 months use 3.5 tube
  • if 1 year use 4.0
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15
Q

What is important regarding ETT size?

A
  • should have audible air leak @ 15-25 cmH2O pressure
  • excessive tube size causes post op croup more than any other factor
    • always prepare calculated tube size and 1/2 size smaller **
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16
Q

What is important in obtaining a pre-op history?

A
  • current complaint: how it affects resp system
  • past resp. History- neonate and family hx
  • review of systems- assess functional state of pt’s lungs
    • ** this is more useful than lab data ***
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17
Q

What is important in obtaining a pre-op physical exam?

A
  • exam of a calm child provides much more info
  • character of respirations- depth, rate
  • work of breathing- nasal flaring, retractions
  • URI- bilateral breath sounds
    • if URI within past 2-6 weeks —> significant risk of bronchospasm
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18
Q

What is a laryngospasm?

A
  • sustained tight closure of the vocal cords during light plane of anesthesia (creates central disinhibition)
  • caused by stimulation to the SLN—> contracts adductor muscles of larynx
    • lateral cricoarytenoids, thyroarytenoids and cricoarytenoids
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19
Q

What causes laryngospasm?

A
  • inhaling volatile agents
  • excessive airway secretions
  • presence of URI (hyper-irritable)
  • manipulation of airway (intubation/extubation)
  • stimulating of visceral nerve endings in pelvis, abdomen, and thorax
20
Q

How is laryngospasm treated?

A
  • remove stimulus and debris—> suction
  • deepen anesthesia
  • 100% O2 via tight fitting mask
    • sustained positive pressure ~ 30-40 cmH2O
  • manual forward displacement of mandible
  • if airway maneuvers fail—> atropine, succinylcholine and consider intubating
    • succinylcholine 0.4mg/kg IV, or 4mg/kg IM
21
Q

What are some facts about post laryngeal edema?

A
  • greatest incidence in kids 1-4 years, but can occur in all ages
  • caused by:
    • mechanical trauma to airway during intubation
    • placement of ETT that is too big (no leak at 40cmH2O)
22
Q

How is post intubation laryngeal edema treated?

A
  • humidify inspired gases
  • racemic epi—> vasoconstricts capillaries in subglottic mucosa
  • reintubate/tracheostomy
23
Q

What is epiglottitis?

A
  • a rare cause of infectious upper airway obstruction in kids
    —> caused by influenza B
  • occurs in 3-6 year olds mainly
24
Q

What are the pathology and S/S of epiglottitis?

A

Patho—> septicemia (systemic) with local erythema and edema- worse in the epiglottis, aryepiglotic folds and supraglottic connective tissue
S/S:
- rapid progression <24 hours
- dysphasia, dysphasia, drooling, inspiratory strider, distress, high fever >39ËšC

25
How is epiglottitis treated?
O2, urgent intubation (under GA in the OR) - abx - antipyretics - fluids
26
What kind of anesthetic management must be done with epiglottitis?
- transfer to OR - do not upset or agitate the child * * ENT MUST BE PRESENT *** - smooth, controlled inhalation induction with SEVO—> keep child in sitting position—> add CPAP to circuit - obtain IV—> give atropine - achieve stage 3 - use small ETT * maintain spontaneous ventilation - dx is confirmed by ENT surgeon via direct laryngoscopy
27
What are anesthetic implications with epiglottitis?
Expect slow induction d/t partially obstructed airway - inflamed airway increases potential for coughing, breath holding and laryngospasm - CV depressant effect of IA are magnified d/t hypovolemia - have rigid ventilating bronchoscope available and surgical airway equipment - identifying structures may be difficult with severe swelling * * may need to replace oral ETT with nasal tube for 48-96 hours
28
In a child with epiglottitis, when would you consider extubating?
- when temperature and WBC decrease - an audible air leak is heard around ETT * * extubate only after direct laryngoscopy in OR under GA to confirm swelling is resolved
29
What is laryngotracheobronchitis?
Croup, subglottic infection (Accounts for 99% of infectious upper airway obstruction in kids) - mucosal/submucosal edema within cricoid ring- decreases luminal size - gradual onset/progression - 24-72 hours - hx of URI progressing to hoarse cry or barking cough - low grade fever <39ËšC
30
What is laryngotracheobronchitis caused by?
Parainfluenza type 1 and 2 Influenza A Respiratory syctitial virus —> occurs in kids <2 years
31
How is laryngotracheobronchitis treated?
- O2 with cool mist - racemic epi (Ăź blocker effect) - albuterol - corticosteroids - antipyretics - intubation is rare unless exhaustion occurs
32
What are s/s of foreign body aspiration and where is it most likely to occur?
``` * most likely to occur right mainstem bronchus S/S: - coughing - wheezing - decreased air entry into affected lung - URI - PNA ```
33
What is the treatment for foreign body aspiration?
- laryngoscopy or endoscopic removal - best if removed within 24 hours if FB left, risk of: - migration of aspirated material - PNA, residual pulmonary disease
34
Anesthetic management for foreign body aspiration?
Induction technique depends on severity of airway obstruction ** with airway obstruction ** —> inhalation of volatile agent in O2, maintaining spontaneous ventilation - avoid NDNMBs - without obstruction—> standard IV induction - positive pressure may migrate FB - direct laryngoscopy: anesthetize the vocal cords to prevent laryngospasm—> 1% lidocaine, 1-2 mg/kg POST OP - Racemic epi - corticosteroids
35
What are complications of foreign body aspiration?
- airway obstruction - fragmentation of FB - hypoxemia - hypercarbia * * subglottic edema from trauma to tracheobronchial tree (from FB instrumentation)
36
What are clinical applications for a tonsillectomy and andenoidectomy?
- upper airway obstruction - massive hypertrophy - chronic URI - OSA
37
Anesthetic management for a T and A?
- premeditate with P.O. or intranasal midazolam - IH induction with Sevo - intubate deep: sevo + propofol + short acting NDNMBs - analgesia: morphine or fentanyl - steroids: dexamethasone * * EXTUBATE WHEN FULLY AWAKE **
38
How is post- tonsillectomy bleeding characterized?
- early: within 1st 24 hours (90% occurs within the 1st 6 hours) - secondary delayed: 24 hours to 3 weeks—> peak on POD 7 (On day 7 people get daring and try to eat Doritos)
39
Which populations are at greatest risk for post-tonsillectomy bleeding?
- older patients - presence of inflammation or infection (hx of strep) - pre-op aspirin, NSAIDS - platelet inhibition - coagulopathy
40
How is post-tonsillectomy bleeding prevented?
- careful direction in tonsillar capsule - meticulous hemostasis - avoid surgery during/immediately after acute inflammation/infection * avoid blind, vigorous suctioning * avoid use of NSAIDS
41
What are s/s of post-tonsillectomy bleeding and how does it present clinically?
``` S/S: - frequent swallowing - throwing up blood Clinical presentation: - hypovolemia - anemia - agitation - shock - stomach full of blood - active bleeding—>poor visualization of glottis ```
42
What is important to include in your pre-op eval for a tonsillectomy?
- assess volume status: BP, HR, UOP, mucous membranes, skin turbot, sensorium Labs: H/H, urine SG/osmolality - establish IV access - for IVF or immediate transfusion *** SEND FOR BLOOD ***
43
Anesthetic management for a tonsillectomy?
- full stomach—> RSI, cricoid pressure - maintain O2, IH, opioids - 2 suctions, 2 blades/handles, multi-styletted cuffed ETTs * atropine, propofol, Etomidate, ketamine, rocuronium, succinylcholine Emergence—> suction stomach, awake extubation
44
What is choanal atresia?
Occlusion of one or both posterior nares - partially or totally bony in 90% of cases - frequently associated with craniosynostosis
45
What is so dangerous about choanal atresia?
- infants are obligate nose breathers—> bilateral choanal atresia causes suffocation —> must keep mouth open with OPA or large rubber nipple ** surgical correction with tracheostomy must be performed within the 1st few days of life
46
What is true regarding unilateral choanal atresia?
May go undiagnosed for years—> eventual diagnosis d/t presence of intractable unilateral nasal drainage
47
Anesthetic management in choanal atresia?
- awake intubation with oral rae - maintain O2/N2O/IH, NDNMBs, opioids Post-op: - intermittent airway obstruction may persist for some time—> must monitor until patency assured - stents are placed - transfer baby to ICU

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