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SNRAObPedGer > Pediatric AIRWAY Lecture 2B > Flashcards

Pediatric AIRWAY Lecture 2B Flashcards

1
Q

Tongue position of Peds

A

Large in proportion to oral cavity →obstruction!
Tongue base close to larynx →harder visualization
❑Straight blade

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2
Q

Larynx position Peds

A

❑Higher @ C3-4
❑Higher in premature infants
❑Adult @ C4-5

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3
Q

Visualization of tongue harder in syndromes associated

mandibular/midfacial hypoplasia such as in

A

❑Glossoptosis

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4
Q

Epiglottis of Peds

A

❑Narrow, omega, angled away from tracheal axis (parallel in adults)
❑Harder to lift

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5
Q

Subglottis of the Peds is the _______and ETT will ___________

❑Rapid grow during _________
❑Adult proportions __________

A

Functionally narrowest portion of upper airway
ETT meets resistance below cords
first 2 yrs of life
10-12 yrs

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6
Q 
The Larynx of Peds
One bone =
How many cartilages?
What are the single cartilages? 
Single:
Paired:
A

Hyoid
11
thyroid, cricoid, epiglottic
arytenoid, corniculate, cuneiform, triticeal

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7
Q
  • Arytenoid rest on ______

* Suspended by

A
  • rest on top, connects with superoposterior part of cricoid cartilage
  • ligaments from base of skull
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8
Q

Laryngeal Tissue folds

A 
Aryepiglottic fold (paired)
❑Epiglottis to arytenoids
❑False cords
Vestibular folds  (Thyroid cartilage to arytenoids)

❑True vocal cords
(Thyroid cartilage to arytenoids)

❑Interarytenoid fold (single)
(Bridge)

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9
Q

Larynx innervation

Completely innervated by the __________

A

Mucosa tightly adhered at laryngeal surface of epiglottis and vocal cords
◦ Acts as barrier to inflammation from above/below

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10
Q

What nerve mediates bronchospiasm

A

RECURRENT

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11
Q

What nerve mediates input

A

VAGAL

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12
Q

Thyroidectomy concerns ?

A

Recurrent laryngeal nerve damage

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13
Q

Comment on superior laryngeal / Recurrent Laryngeal

motor/ sensory

A

Superior laryngeal
◦ Sensory: internal branch = sensory in supraglottic area
◦ Motor: external branch = cricothyroid muscle
Recurrent laryngeal
◦ Sensory: subglottic larynx
◦ Motor: all other laryngeal muscles

Blood supply
◦ Superior + inferior thyroid arteries

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14
Q

What happens to Larynx upon inspiration?
pulled _____via _________ pressure
stretched ___________
_______Distance between _______+ vocal folds
Intrinsic laryngeal muscles contract to move ________ laterally and posteriorly
________Interarytenoid distance,

A

Inspiration
◦ Pulled ↓via negative intrathoracic pressure
◦ Stretched longitudinally
↑ distance between vestibular + vocal folds
Intrinsic laryngeal muscles contract to move arytenoids laterally and posteriorly
◦ ↑ interarytenoid distance, stretching aryepiglottic, vestibular, and vocal folds

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15
Q

Larynx overall during inspiration

A 
Overall = laryngeal inlet becomes longer (opening telescope) and
wider = more airflow
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16
Q

What happens to Expiration for Larynx

A

◦ Larynx becomes shorter (closing telescope)

◦ Everything reverts back to normal and reduces tensions → thicken

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17
Q 
Trying to breathe out against closed vocal cords
Voluntary =
◦ Contraction of\_\_\_\_\_\_\_\_\_
◦ Intrinsic:+\_\_\_\_\_\_\_\_\_\_\_\_
◦ Extrinsic:
A

Valsalva maneuver
laryngeal muscles
Everything gets tighter, closer, shorter
Pulls larynx upward

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18
Q

Involuntary =

Major differences:

A

laryngospasm
Spasm accompanied by inspiratory effort
◦ Upper portion of larynx left partially open during mild laryngospasm = highpitched inspiratory stridor

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19
Q

Swallowing
◦ Similar glottic closure as with Valsalva
1._______
2._______
All of these reflexes go away when you are_____

A
  1. Apposition of laryngeal folds
  2. Upward movement of larynx:Epiglottis folds over opening
    - sedated
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20
Q

Phonation
◦
◦ Vocal cords vibrate produces =
◦ ONLY

A

Alternating cricothyroid angle + medial movements of arytenoids during expiration sound
- laryngeal function that alters cricothyroid angle

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21
Q

Obligate nose breathing
◦ Obstruction of nares =________
◦ Uncoordinated= __________

A

-asphyxia
-oropharyngeal muscle relationship with
respiratory drivers

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22
Q

◦ Large tongue naturally obstructs___________
◦ Mouth breathing begins_________
◦ Sometimes the infants can breath

A

the oropharynx
around 3-5 months
through their mouth

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23
Q

Intrathoracic Obstruction

A

Most likely due to Foreign bodies swallowed

Other cause vascular ring

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24
Q

Lower obstruction in

A

Asthma, bronchiolitis, can lead to tracheal and bronchial collaps

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25
Q

Vigorous crying can lead to

A

extreme transluminal pressure THAT can lead to dynamic airway collapse

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26
Q

WOB

A

Product of pressure and volume (Change in P/V)

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27
Q

Small airway resistance account for most of

A

WOB in a child (small diameter, increase compliance.

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28
Q

Increase in airway resistance, decrease lung compliance

A

Increase transpulmonary pressure required to produce given tidal volume = increase WOB

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29
Q

Pressure changes leads to

A

change in volume

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30
Q

Smallest change in pressure

If compliance is down

A

give you the greatest change in volume

you have to generate more pressure to give same breath.

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31
Q

WOB ________to ___power of radius of lumen during laminar florw and to th 5th power during turbulenr flow

A

inversely proportional ; 4th

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32
Q

Other causes of WOB

A 
long ETT with small diameter (straw)
Obstructed ETT (phelgm, if you too deep into carina) 
Those 2 leads to Increase O2 consumption= increase O2 demands = exhaustion = respiratory failure.
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33
Q

Less type I fibers in the young patient

A

Tru

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34
Q

Airway obstruction during anesthesia

A

Loss of muscle tone in pharyngeal/laryngeal structures
Progressive loss of ton with deepening of anesthesia lead to progressive airway obstruction at soft palate and Epiglottis
SNIFFING HELPS but DOES NOT CHANGE POSITION OF THE TONGUE< in order to remove tongue–> CHIN lift, JAW thrust with large tonsils

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35
Q

Tighten the APL

A

Give more pressure in the system, acts as a CPAP

36
Q

What is the most effective means to improve airway patency and ventilation in patient under ADENOTONSILLECTOMY?

A

Jaw thrust maneuver

37
Q

Lateral positioing improves all

A

Airway dimension

38
Q

What does the CPAP doe

A

It increases transverse dimension of airway

39
Q

Evaluation of airway

A

Hx of congenital syndrome (difficult laryngoscopy)

Large NECK CIRCUMFERENCE (assss for snoring, asthma, HTN, DM,) or adverse periop resp events but not laryngoscopy

40
Q

Characteristic of

A

Congenital syndrome (Treacher collins)
-Inability to open moutn *TMJ, ankylosis micrognata PIerrer Robbin
Massive glossoptodis (Beckwith-w-edemann syndrome)
Fused cervical spine (Kliper-Feil syndrome)
Oropharyngel space occupying lesions

41
Q

Evaluation of airway

A

Medical Evaluation: Snoring, URI, Croup, Noisy breathing, voice tone, asthma, FB aspiration, Previous anesthesia issues, SMOKING , PREMATURITY

42
Q

Physical Exam of the child

A 
Facial expression
Characteristric of breathing
Mouth opening and zie
MALLAMPATI Score, 
Loose /missing 
Teeth size,
43
Q

Stridor

A 
high pitches
Inspiratory = EXTRA THORACIC LESIONS
Worry about (epiglottis (most common) croup and extrathoracic Foreign bodis)
Both Inspiratory or expiratory = Intrathoracic lesion (FB vascular ring) ]
44
Q

Microtia

A

Underdeveloped pinna-= Small external ear
Mandibular hypoplasia
BILATERAL : ASSOCIATED wiTh HARD INTUBATION

45
Q

Evaluation of Airway with congenital Anomalies

A

Conditions and anesthesia consideration

46
Q

Mask Venvtilation

A

Clear mask to see color of lips and detect vomitus

47
Q

New practitioners commonly compress______which leads to _______

A

SUBMENTAL TRIANGLE which leads to OCCLUSION

Jaw thrust opens mouth, pull tongue/soft tissue off posterior pharyngeal wall

48
Q

Airway management

A

Intubation
◦ ↑risk of obstruction with trauma
◦ Lifting base of tongue lifts epiglottis, exposing glottic opening

Optimal position depends on age
◦ Older children (>6 yrs) and adults
◦ Extending head at atlantooccipital joint = sniffing position
◦ Aligns 3 axes: oral, pharyngeal, tracheal

Infants, younger children
◦ Only needs head extension to align = fat heads

49
Q

Putting a blanket under head helps by

A

anterior displacement of cervical spine = good view

50
Q

20-25 cm H20 cuff pressure why?

A

Careful not to compress blood vessels, can lead to decrease perfusion

51
Q

> 2 yrs ◦ Uncuffed:______ calculation
Cuffed: ______(calculation)

◦ < 2 yrs ◦ Size charts, weight

A

(age+16)/4

(age/4)+3

52
Q

Blades

Traditional (which one deemed superior?)

A

◦ Traditionally straight blade = superior

◦ Both are fine if appropriately sized

53
Q

Endotracheal tubes ◦ Standardized________

External diameter

A
  • inner diameter

- varies by manufacturer

54
Q

◦ Always do a _______

A

LEAK TEST

55
Q

Old wisdom
◦ Allows larger tube = less airway resistance
Uncuffed Advantage?

A

◦ Uncuffed ETT < 8 yrs

◦ Exerts minimal pressure on cricoid cartilage = less incidence of croup

56
Q

Advantages of CUFFED TUBES

A

Cuffed tubes
◦ Less intubating to find appropriate size for leak test
◦* REDUCED subglottic pressure
◦ DECREASED OR pollution/COST of anesthetic
◦ **↓risk of aspiration (nothing can get around)
◦** Accurate pCO2 reading (ONLY ACCURATE WAY TO GET pCO2)
◦ **Ability to deliver more pressure for restrictive lung disease
◦ Ability to control cuff pressure
◦ Minimal increased risk of post extubation stridor

57
Q

Uncuffed tube

A

No wiggle room for lead

58
Q

Size Chart

A

KNOW

59
Q

Insertion distance

A

At the lips
(Age/2 )+12
(Weight in Kg/5 ) +12

60
Q

If no mark to measure distance

A

After you past vocal cords , 1 cm

If you have cuffed tube ,

61
Q

For premies distance mnemotic

A

Premies:
• Kg: 1 2 3 4
• Cm: 7 8 9 10

62
Q

Complications of Tracheal Intubation: Post intubation risks

What is the treatment of croup

A 
ETT with OD too large for child’s airway (no leak at > 25 cm H2O)
◦ Unusual positioning
◦ Repeated attempts at intubation
◦ Traumatic intubation
◦ Ages 1-4yrs
◦ Surgery duration > 1 hr
◦ Coughing (bucking) on ETT
◦ Hx croup

Nebulized racemic epi (0.5mL of 2.25%) w/dexamethasone

63
Q

Complications of Tracheal Intubation: SUBGLOTTIC STENOSIS

A 
Similar to croup 
Risk 
Hypotension
◦ Sepsis
◦ Infection
◦ Chronic illness
64
Q

Subglottic stenosis

Croup

A

Permanent subglottic stenosis

Croup temporary

65
Q

Alternative to ETT for airway management during GA
Replaces face masking during maintenance of anesthesia
Sizing guidelines_______
Good for spontaneous ventilation
◦

A

Laryngeal Mask Airway (LMA)
-based on weight

Mechanical = insufflation of stomach → regurgitation
◦ Keep pressures < 17 cm H2O

66
Q

LMA has Various different types (___

A

proseal, flexible, supreme, fast trach, igel)
insertion techniques
airway algorithm

67
Q

More anesthesia with

A

insertion of LMA

68
Q

Airway Management: Abnormal

A

❑Have multiple backups (including ENT surgeon wiling to do trach )
❑Order diagnostic imaging PRN (Ultrasound)

69
Q

What helps detect subglottic stenosis?

A

Ultrasound

70
Q

First choice of management of airway managemet

Maintain ?

A

Maintain spontaneous ventilation
❑NMB can result in total airway obstruction
❑Loss of spontaneous breath sounds

71
Q

For airway management : abnormal

A

Modified awake/mildly sedated intubation
❑Ketamine 0.25/0.5mg/kg IV q 2 min
❑Topical anesthesia
❑Nebulized lidocaine, translaryngeal delivery of lidocaine, direct application, (Max limit on lidocaine of 4 mg/kg (no benzocaine!)

72
Q

Why do we avoid benzocaine?

A

Can lead to Methomoglobinemia

73
Q

Unanticipated Difficult Airway

A

1`. Call for help

  1. Mask ventilate if possible (may use to
  2. oral airway, blade, use a stylet
74
Q

> 2 direct laryngoscopies =_______And ________
Limit ___________
May use Passive oxygenation in the meantime to Keep oxygen going?

A

high failure rate, ↑severe complications
laryngoscopy attempts

◦ High-flow nasal cannula
◦ Modified nasal trumpet

75
Q

Extubation

Dont be afraid to use

A

◦ 0.5-1mg/kg (max 20 mg) IV dexamethasone for airway edema
◦ Cook airway exchange catheter
Don’t be afraid to use multi-handed mask ventilation techniques

76
Q

Cervical Spine anomalies: Etiology Congenital ***

A 
****Down syndrome
Klipper Feil malformation
Goldenhar syndome
Pierre Robin
*****Torticollis
77
Q

Cervical Spine anomalies: Etiology Traumatic

A

Fracture
Subluxation
**Neck burn contracture

78
Q

Cervical Spine anomalies: Etiology Inflammatory

A

***Rheumatoid arthritis (RA)

79
Q

Cervical Spine anomalies: Mtabolic

A

Mucopolysaccharidosis (moquio syndrome)

80
Q

Percutaneous Cricothyrotomy

A

• Not recommended if child is < 5 yo (membrane has very
small width) (trach in general not recommended in less than 5)
•Only a means for oxygen insufflation and DOES NOT RELIABLY provide adequate ventilation

81
Q

Fiberoptic Intubation
There is no _________
BEST with patient with

A

No SNIFFING Head flat on table with slight extension at
atlantooccipital joint
UNSTABLE C-SPINE
Nasal approach can lead to = nose bleeds (give afrin or cocaine preop)
Oral approach = need intubating bite block required

82
Q

Retromolar Approach with Miller

A 
Displace less soft tissue
Side view
Decrease angle, shorter distance
Tilt head to the left
go behind molar
Pick up epiglottis on the side.
EASIER
83
Q

Videolaryngoscopes advantages

A

Improved view of glottis, less strength required, opportunity for show and tell

Angulated blades (glidescope)
** Better for anterior airways, but harder to get ETT in the right spot (hockey stick stylet)
Glidescope
◦ Sizes 0-4
◦ High resolution with antifog system built in
◦ 4-step technique!
◦ Sweeping not necessary, can be inserted midline
◦ Optimize view, try backing up if you just see pink tissue

Curved blades (CmaC, mac with camera) 
◦ Easier to physically intubate, LESS EFFECTIVE FOR ANTERIOR AIRWAY, good for learning!
84
Q

For nasal, fiberoptic intubation

for oral

A

Bevel up

Bevel down

85
Q

Compliance and elasticity of the lung relationships

A

Inversely related

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