Pediatric Airway (Fundamentals + Difficult Airway) Flashcards
What are the fundamentals of the pediatric airway? (5)
-infant tongue is relatively larger in production to the rest of the oral cavity (can easily obstruct)
-nasal passages are relatively narrow
-pronounced salivary secretions
-large tonsils and adenoids
-prominent occiput
Describe the position of the larynx in pediatrics compared to adults
larynx is higher (more cephalad) in neonates to 2 years of age
larynx is more anterior with a more acute angle
C3-C4 (adult C5-6)
What blade is more effective in neonates and why?
a straight laryngoscope blade is more effectively lifting the tongue from the field of view
Describe the epiglottis in pediatrics compared to adults
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 the view of the vocal cords and is more difficult to lift
Describe the vocal cords in pediatrics compared to adults
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
Describe the trachea in pediatrics compared to adults
shorter then adults
infants- 4-5cm
adults 10-12cm
Describe the subglottic opening in pediatrics compared to adults
narrowest portion of the child’s larynx is the cricoid cartilage (until about age 8)
funnel vs elliptical shaped (anterior posterior dimension being greater than the transverse dimension)
What is the narrowest portion of the adult airway?
glottic opening
What is the cricoid cartilage?
the only complete ring in the larynx and is not distensible
What does a tight fitting ETT do to the tracheal mucosa?
if too tight can cause edema, reduce luminal diameter and result in post-extubation croup
Describe the relationship between edema and resistance in an infant
the subglottic region is smaller in the adult the same degree of airway edema results in greater resistance in the infant
What are ways to evaluate the airway? (9)
mallampati (mouth opening) and manidble
history of syndrome/congenital anomalities or physical findings
loose or missing teeth
recent respiratory infections
work of breathing (rate, nasal flaring, accessory muscles)
snoring/nosy breathing at night
baseline oxygen saturation
asthma/smoking
global apperance
What are the unique anatomic features of the pediatric airway?
prominent occiput
cephalad larynx
epiglottis angled over the vocal cords
What are the anesthesia implications and management of the prominent occiput?
neck flexed in supine position, upper airway obstruction likely, oral pharyngeal/laryngeal axes are not lined up, making laryngoscopy difficult
shoulder roll for infants
What are the anesthesia implications and management of the cephalad larynx?
larynx seems more anterion, entire tongue is in oral cavity increasing risk of obstruction
laterial approach to laryngoscopy, oral airway to relieve obstruction
What are the anesthesia implications and management of the epiglottis angled over the vocal cords?
epiglottis often obstructs the view of vocal cords
straight laryngoscope blade in children under 3 years of age
What is the most frequent mistake in the physiological and emotional characteristics of pediatrics?
late recognition of upper airway obstruction
What are signs of upper airway obstruction?
evidence of airway obstruction includes tracheal tug, paradoxical chest wall movement, absence of movement in the ambu breathing bag or capnography tracing
What are common mistakes seen in pediatric airway management?
inadequate sedation depth
overly aggressive bag mask ventilation
What are consequences of inadequate sedation depth?
struggling, breath holding, partial airway obstruction, rapid desaturation
What are consequences of overly aggressive bag mask ventilation?
leads to gastric insufflation, reducing volumes, and increased risk of regurgitation
What are indicators of difficult airway in the pediatric patient?
occurs in infant age group
craniofacial anomalies
congenital cardiac anomalies
What correlates with cormack-lehane view?
mallampati score
What should be observed during the child’s airway exam?
observe the child’s profile and look for a recessed or smaller normal mandible, limited mouth opening, prominent dentition, facial asymmetry and cleft palate
Name the syndrome and conditions associated with difficult airways
CHARGE
Trisomy 21/Down syndrome
Hunter and Hurler Sydrome
Cleft Palates
Goldenhar
Pierre Robin
Treacher Collins
Apert
Juvenille Arthritis
trauma/burns
oral tumors
kippel-feil
muccopolysac haridosis
What are induction strategies for the difficult airway patient?
maintain spontaneous respirations whenever possible
Delay positive pressure ventilation and muscle relaxation (mediastinal tumors, epiglottis, foreign body, limited mouth opening)
a nasopharyngeal airway or small ETT inserted in the nasopharynx can act as an oxygen conduit during intubation attemps
cautious titration with a combination of propofol, ketamine, dexmedetomidine, midazolam
What is KEY?
POSITIONING
lining up the axis,
laryngeal pharyngeal and oral axes
What should be considered when choosing an blade size?
size of the patient’s mandible rather then the age or weight
What blade is best for micrognathic/ retrognathic patients
straight blade
How do you insert your blade?
insert on extreme right
may be helpful to have an assistant pull the back right corner of the child’s mouth
When is a LMA no useful?
when the obstruction is beyond the glottis
requirement of high ventilation pressures
patients at risk for pulmonary aspiration
How do you insert a video laryngoscope?
insertion technique is midline
What do you do in the unanticipated difficult airway?
act quickly and calmly and solicit experienced help
if BMV is easy, reverse and wake child up
if not able to BMV, immediately request expert hepl including ENT, anesthesia provider or ECMO depolyment
2 hand mask, LMA insertion, emergency invasive airway access
(cricothyroidotomy, rigid bronchoscopy, surgical tracheostomy)
What supplies is needed for a surgical cric?
syringe 1/2 filled with saline
IV catheter
15mm adapter from ETT
Describe the eight steps of an unexpected difficult airway
increase O2 to 100% and maintain continuous O2 flow during airway management
call for help, surgical airway expert
if unable to BMV, ask for two handed assistance and insert oral airway/ nasal airway/ LMA, decompress stomach with OG tube and reverse
if SV: awake and reverse
after two attempts to BMV: change providers and consider alternative approaches to intubation
if macroglossia or mediastinal mass- consider prone or lateral
unable to ventilate: emergency noninvasive airway (rigid bronchoscope)
older: Jet ventilation or emergency invasive surgical airway (cric or trach)
What are alternative approaches to intubation?
different blade
re-position head
different provider
video laryngoscope
bougie
intubating LMA
fiberoptic scope
intubating stylet
blind oral
blind nasal
What are challenging pediatric airway PEARLS (7)
known vs unknown
assess previous airway records
ensure pediatric airway adjuncts and pediatric experienced help
light to no sedation before establishing an airway
light to no sedation before establishing an airway
maintain spontaneous respirations whenever possible
consider fiberoptic intubation through an LMA
cannot ventilation cannot intubate (immediately establish a surgical airway)
what are the most common errors noted in malpractice
lack of equipment in inappropriately size equipment
inadequate skilled help
failure or delay in calling for help
failure to attempt cricothyrotomy soon enough
