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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
Vigorous crying can lead to
extreme transluminal pressure THAT can lead to dynamic airway collapse
26
WOB
Product of pressure and volume (Change in P/V)
27
Small airway resistance account for most of
WOB in a child (small diameter, increase compliance.
28
Increase in airway resistance, decrease lung compliance
Increase transpulmonary pressure required to produce given tidal volume = increase WOB
29
Pressure changes leads to
change in volume
30
Smallest change in pressure | If compliance is down
give you the greatest change in volume | you have to generate more pressure to give same breath.
31
WOB ________to ___power of radius of lumen during laminar florw and to th 5th power during turbulenr flow
inversely proportional ; 4th
32
Other causes of WOB
``` 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. ```
33
Less type I fibers in the young patient
Tru
34
Airway obstruction during anesthesia
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
35
Tighten the APL
Give more pressure in the system, acts as a CPAP
36
What is the most effective means to improve airway patency and ventilation in patient under ADENOTONSILLECTOMY?
Jaw thrust maneuver
37
Lateral positioing improves all
Airway dimension
38
What does the CPAP doe
It increases transverse dimension of airway
39
Evaluation of airway
Hx of congenital syndrome (difficult laryngoscopy) | Large NECK CIRCUMFERENCE (assss for snoring, asthma, HTN, DM,) or adverse periop resp events but not laryngoscopy
40
Characteristic of
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
Evaluation of airway
Medical Evaluation: Snoring, URI, Croup, Noisy breathing, voice tone, asthma, FB aspiration, Previous anesthesia issues, SMOKING , PREMATURITY
42
Physical Exam of the child
``` Facial expression Characteristric of breathing Mouth opening and zie MALLAMPATI Score, Loose /missing Teeth size, ```
43
Stridor
``` 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
Microtia
Underdeveloped pinna-= Small external ear Mandibular hypoplasia BILATERAL : ASSOCIATED wiTh HARD INTUBATION
45
Evaluation of Airway with congenital Anomalies
Conditions and anesthesia consideration
46
Mask Venvtilation
Clear mask to see color of lips and detect vomitus
47
New practitioners commonly compress______which leads to _______
SUBMENTAL TRIANGLE which leads to OCCLUSION | Jaw thrust opens mouth, pull tongue/soft tissue off posterior pharyngeal wall
48
Airway management
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
Putting a blanket under head helps by
anterior displacement of cervical spine = good view
50
20-25 cm H20 cuff pressure why?
Careful not to compress blood vessels, can lead to decrease perfusion
51
> 2 yrs ◦ Uncuffed:______ calculation Cuffed: ______(calculation) ◦ < 2 yrs ◦ Size charts, weight
(age+16)/4 | (age/4)+3
52
Blades | Traditional (which one deemed superior?)
◦ Traditionally straight blade = superior | ◦ Both are fine if appropriately sized
53
Endotracheal tubes ◦ Standardized________ | External diameter
- inner diameter | - varies by manufacturer
54
◦ Always do a _______
LEAK TEST
55
Old wisdom ◦ Allows larger tube = less airway resistance Uncuffed Advantage?
◦ Uncuffed ETT < 8 yrs | ◦ Exerts minimal pressure on cricoid cartilage = less incidence of croup
56
Advantages of CUFFED TUBES
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
Uncuffed tube
No wiggle room for lead
58
Size Chart
KNOW
59
Insertion distance
At the lips (Age/2 )+12 (Weight in Kg/5 ) +12
60
If no mark to measure distance
After you past vocal cords , 1 cm | If you have cuffed tube ,
61
For premies distance mnemotic
Premies: • Kg: 1 2 3 4 • Cm: 7 8 9 10
62
Complications of Tracheal Intubation: Post intubation risks | What is the treatment of croup
``` 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
Complications of Tracheal Intubation: SUBGLOTTIC STENOSIS
``` Similar to croup Risk Hypotension ◦ Sepsis ◦ Infection ◦ Chronic illness ```
64
Subglottic stenosis | Croup
Permanent subglottic stenosis | Croup temporary
65
Alternative to ETT for airway management during GA Replaces face masking during maintenance of anesthesia Sizing guidelines_______ Good for spontaneous ventilation ◦
Laryngeal Mask Airway (LMA) -based on weight Mechanical = insufflation of stomach → regurgitation ◦ Keep pressures < 17 cm H2O
66
LMA has Various different types (___
proseal, flexible, supreme, fast trach, igel) insertion techniques airway algorithm
67
More anesthesia with
insertion of LMA
68
Airway Management: Abnormal
❑Have multiple backups (including ENT surgeon wiling to do trach ) ❑Order diagnostic imaging PRN (Ultrasound)
69
What helps detect subglottic stenosis?
Ultrasound
70
First choice of management of airway managemet | Maintain ?
Maintain spontaneous ventilation ❑NMB can result in total airway obstruction ❑Loss of spontaneous breath sounds
71
For airway management : abnormal
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
Why do we avoid benzocaine?
Can lead to Methomoglobinemia
73
Unanticipated Difficult Airway
1`. Call for help 2. Mask ventilate if possible (may use to 3. oral airway, blade, use a stylet
74
> 2 direct laryngoscopies =_______And ________ Limit ___________ May use Passive oxygenation in the meantime to Keep oxygen going?
high failure rate, ↑severe complications laryngoscopy attempts ◦ High-flow nasal cannula ◦ Modified nasal trumpet
75
Extubation Dont be afraid to use
◦ 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
Cervical Spine anomalies: Etiology Congenital ***
``` ****Down syndrome Klipper Feil malformation Goldenhar syndome Pierre Robin *****Torticollis ```
77
Cervical Spine anomalies: Etiology Traumatic
Fracture Subluxation ****Neck burn contracture
78
Cervical Spine anomalies: Etiology Inflammatory
***Rheumatoid arthritis (RA)
79
Cervical Spine anomalies: Mtabolic
Mucopolysaccharidosis (moquio syndrome)
80
Percutaneous Cricothyrotomy
• 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
Fiberoptic Intubation There is no _________ BEST with patient with
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
Retromolar Approach with Miller
``` 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
Videolaryngoscopes advantages
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
For nasal, fiberoptic intubation | for oral
Bevel up | Bevel down
85
Compliance and elasticity of the lung relationships
Inversely related

SNRAObPedGer (25 decks)

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