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Concepts 2 > Pediatric Respiratory System and Anesthesia > Flashcards

Pediatric Respiratory System and Anesthesia Flashcards

1
Q

Pedi Respiratory Anatomy

A

Tongue: Large In Infant In Relation To Oral Cavity
Larynx: Infant Larynx (C3-C4)
Larynx At An Acute Angle & Appears To Be Anterior
Miller Blade And External Laryngeal Pressure
Epiglottis: Narrow, Long, U-shaped In Infant.
Cricoid Cartilage: Narrowest Part Of The Upper Airway In The Infant
Large Occiput - Up To 3 Yrs Of Age –> Sniffing Position

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2
Q

Pedi vs Adult airway: 5 differences

A
  1. More rostral larynx
  2. Relatively larger tongue & Obligate Nasal Breathers
  3. Angled vocal cords
  4. Differently shaped epiglottis
  5. Funneled shaped larynx
    *Narrowest part of pediatric airway is cricoid cartilage
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3
Q

Different shaped epiglottis

A

newborn - true U shape
Child - more rounded out
adult )

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4
Q

Sniffing position pedi

A

Keep their head NEUTRAL

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5
Q

Prenatal lung development - 1st phase

A

PseduGlandular Period: 17th week of gestation; Branching of airways down to terminal bronchioles

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6
Q

prenatal lung development - 2nd phase

A

Canalicular Period: Branching into future respiratory bronchioles; Increased secretary gland and capillary formation

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7
Q

prenatal lung development - 3rd phase

A

Terminal sac (alveolar period): 24th week of gestation
Clusters of terminal air sacs with flattened epithelia

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8
Q

Surfactant

A

Produced By Type II Pneumocytes
Appear 24-26 Weeks (As Early As 20 Weeks)

Maternal Glucocorticoid Treatment
24-48 Hours Before Delivery
Accelerates Lung Maturation & Surfactant Production

Premature Birth – Immature Lungs -> insufficient surfactant
Infant Respiratory Distress Syndrome (HMD) r/t Insufficient Surfactant Production

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9
Q

Prenatal development

A

Proliferation of capillaries around saccules -
26-28th weeks (as early as 24th wk)

Formation of alveoli = 32-36 weeks
Saccules still predominate at birth
Lung fluid - expands airways -> helps stimulate lung growth
Contributes ⅓ of total amniotic fluid
Prenatal ligation of trachea in congenital diaphragmatic hernia
Results in accelerated growth of otherwise hypoplastic lung

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10
Q

Perinatal Adaptation

A
  • First breaths: Up To 40 (To 80 Cmh2o Needed)
    To Overcome High Surface Forces
    To Introduce Air Into Liquid-filled Lungs
    Adequate Surfactant Essential For Smooth Transition
  • elevator PaO2
  • marked increased pulmonary blood flow: increased Left atrial pressure with closure of foramen ovale
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11
Q

Postnatal Development

A

Lung Development Continues For 10 Years; Most Rapidly during the First Year
At Birth: Terminal Air Sacs (Mostly Saccules)
Tiny! 20- 50 x 107
Only One Tenth Of Adult Number
Development Of Alveoli From Saccules
Essentially Complete By 18 Months Of Age

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12
Q

Control of breathing - perinatal

A

Neonatal breathing is a continuation of fetal breathing
Clamping umbilical cord is important stimulus to rhythmic breathing
Relative hyperoxia of air augments and maintains rhythmicity
Independent of PaCO2; unaffected by carotid denervation
Hypoxia depresses or abolishes continuous breathing

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13
Q

Infant control of breathing: hypoxia

A

Ventilatory Response To Hypoxemia
First Weeks (Neonates)
Transient Increase - > Sustained Decrease
(Cold Abolishes The Transient Increase In 32-37 Week Premature)

By 3 Weeks –> Sustained Increase response

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14
Q

Infant control of breathing: CO2 and hypoxia

A

Ventilatory Response To CO2; Slope Of Co2-response Curve
Decreases In Prematurity
Increases With Postnatal Age

Neonates: Hypoxia
Shifts Co2-response Curve and Decreases Slope
(Opposite To Adult Response)

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15
Q

Periodic Breathing

A

Apneic Spells < 10 Seconds
Without Cyanosis Or Bradycardia
(Mostly During Quiet Sleep)
80% Of Term Neonates
100% Of Pre-terms
30% Of Infants 10-12 Months Of Age

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16
Q

Central Apnea

A

Apnea > 15 seconds or
Briefer but associated with:
- Bradycardia (HR<100)
- Cyanosis or
- Pallor
Rare in full term
Majority of premature infants

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17
Q

Postop Apnea in preemies

A

Pre-terms < 44 Weeks Post-conception Age: Risk Of Apnea = 20-40%
Post-op Apnea Reported In Premature Infants As Old As 56 Weeks PCA

Associated Factors:
- Extent Of A surgery
- Anesthesia Technique
– Anemia
– Post-op Hypoxia

44-60 Weeks PCA: Risk Of Postop Apnea < 5%
Except: Hct < 30: Risk Remains HIGH

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18
Q

Pedi pulmonary physiology - infant

A

Infant: lung volume small with less reserve
Ventilatory requirements/unit lung volume
VO2/Kg 2 x adult value

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19
Q

neonate pulmonary physiology

A

Neonate: Lung compliance high
Chest wall compliance is high
Prone to atelectasis

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20
Q

infant and childhood pulmonary physiology

A

Infancy & Childhood:
Static recoil pressure increases
Compliance decreases
More prone to severe obstruction
Absolute airway diameter is smaller

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21
Q

Mechanics of breathing

A

Compliance:
Neonate has very compliant chest wall, but poor musculature
Neonates and young infants can only increase VE by increasing RR
Chest wall becomes more rigid, elastic recoil increases, and musculature develops by 6 months of age
Improved ability to increase tidal volumes; hence RR decreases

22
Q

Mechanics of breathing: neonate

A

Neonate:
FRC is decreased for first 24 hours of life
Fast inhalational induction
Reduced Type I sustained-twitch fibers in diaphragm
Immature central nervous system
Increased work of breathing due to small airway size
VO2 consumption(5-8 ml/kg/min.)
Neonate minute ventilation: 150-170 ml/kg/min.
(Adult: 80-100 ml/kg/min)
CO2 production is also increased
Oxyhemoglobin curve is shifted to the left
PDA increases intrapulmonary shunt

23
Q

Anesthesia and pedi resp function

A

Changes in respiratory function are similar to adults:
- Decreased FRC
- Decreased VC
- Decreased VT
- Increased ratio of dead space to tidal volume:
0.3 when awake
0.5 when under anesthesia with ETT
0.7 when under anesthesia with face mask
- Increased V/Q mismatch due to alveolar hypoventilation
- Increased closing capacity

24
Q

anesthesia cont.

A

Relaxation of airway muscles predisposes infant and child to airway obstruction
Decreased depth of respirations
Compensation?
Decreased ventilatory response to CO2 and hypoxia

25
Q

pedi anesthesia equipment: oral airway

A

Oral Airway:
Various charts may list slightly different sizes
Preemie: 3.5-4.5 cm
< 1 month old: 4.5-5 cm
1-3 months old: 5-5.5 cm
3-6 months old: 5.5-6.0 cm
6-12 months old: 6.0 cm
1 year old: 6.0-7.0 cm
1-4 years old: 7.0 cm
5-10 year old: 8.0 cm

26
Q

pedi nasal airway

A

Nasal Airway
Avoid In Children Due To Risk Of Injuring Large Adenoids During Placement, Causing Bleeding

27
Q

pedi laryngoscope blades

A
  • Miller (Straight) Blades: Preferred In Infants Due To The Large Tongue And Epiglottis
  • Macintosh Blades Used More Commonly In Older Children
  • Wis-hippel Is Appropriate For Ages 2-6 Years.
28
Q

pedi ETT

A

Cricoid Cartilage Is The Narrowest Part Of The Airway
Size= 16 + Age/4 (age/4+4)
Uncuffed preferred to prevent injury due to anatomy
Cuffed age/4 + 3.5 Cuffed smaller internal diameter than uncuffed
3 CETT has the same diameter as a 3.5 UNETT
Calculate for uncuffed –> Subtract 0.5 for Cuffed

29
Q

pedi ETT distance assessment

A

Assessing adequacy of ETT size once in pt.
Proper fitting ETT: air leak with positive inspiratory pressure < 20 cm H2O.

Estimating proper distance to insert ETT.
Should sit between cords and carina.
ETT should be advanced until 2nd mark on ETT tip passes through the vocal cords.
Age + 10 Rule: @ 1 yr, ETT should be advanced until 11 cm marking at lip.
By age 10-12, cricoid narrowing and angulation of the vocal cords disappears.

30
Q

pedi case with URI

A

Upper Respiratory Infection:
- Children May Get A URI As Often As 6 Times A Year
- Must Distinguish Between URI And Allergies
Obtain A Thorough Hx From Parents
Physical Exam
Child’s Medical History
- URI Within Last 2-4 Weeks
- Infants Have A Higher Risk Of Intra-op And Post-op Problems
- Pediatric Patients Requiring ETT For Procedure Have Increased Incidence Of Postoperative Airway Problems
- If Surgery Canceled In Child With URI, Child Should Be Rescheduled For Surgery 2-4 Weeks Later

31
Q

URI S&S

A

Sx of chronic/recurrent URI seen in children with:
Recurrent tonsillitis
Recurrent otitis media
Cleft Palate
Chronic sinusitis
Atopic child

Sx may persist until the necessary surgery (tonsillectomy, myringotomy) is performed

32
Q

URI anesthesia and intraop management

A

Anesthesia for child with URI requiring surgery:
Preoperative Management: Atropine or Glycopyrrolate, & Sevoflurane

Intraoperative Management:
- Adequate anesthetic depth prior to airway instrumentation
- If possible, avoid ETT
- Monitor breath sounds for wheezing, rhonchi, rales
- Extubate fully awake vs. deep
- Monitor airway patency very closely
- Patient may require “blow by” O2 during transport to PACU

33
Q

Pedi Thoracic Pathology: Infants and Neonates

A

Infants and Neonates:
Pulmonary Sequestration
Pulmonary AV fistulae
Congenital Cysts
Congenital Lobar Emphysema
Diaphragmatic hernia
Esophageal Atresia with Tracheal Esophageal Fistula
PDA
Lung Hypoplasia

34
Q

Pedi thoracic Pathology: childhood

A

Childhood:
Tumors (lymphoma, neuroblastoma, metastatic)
Empyema
Pectus Excavatum = concaved chest
Scoliosis
Congenital branchial cleft cyst

35
Q

Pedi anesthesia management

A

Unlike adults’ infants have improved V/Q with good lung up
- Compliant rib cage
- FRC small
- Because of small size the hydrostatic effect of increased perfusion to down lung is minimized
- Perfusion to dependent lung is reduced
- Infants consume 6 – 8 ml of O2/kg/min

36
Q

OLV and children

A

ETT can be advanced into the mainstem bronchus
Confirm with Fiberoptic
May not seal adequately
Balloon tipped Bronchial blocker
Univent tube
Smallest DLT is 26 Fr. (about 8 yr old)

37
Q

Pedi post-op analgesia

A
  • Local/intercostal block
  • Epidural T 6-8
    Catheter (20 g)
    Hydromorphone 7-8 micrograms (mcgs)
    Bupivicaine .25% 0.5ml/kg initial dose Q 90 minutes in OR
  • Post op
    Bupivacaine 0.1% and hydromorphone mcgs /ml. @ 0.3 ml/kg/hr
    Ondansetron 0.1-0.2 mg kg
    Benadryl 0.5-1 mg/kg
    *Greater rostral spread and more respiratory depression with Morphine than Dilaudid

DONT NEED TO MEMORIZE DOSES OF DRUGS

38
Q

Congenital Neck Masses

A

Dermoid cysts, cystic teratomas, cystic hygroma, lymphangiomas, neurofibroma, lymphoma, hemangioma

39
Q

Congenital Anomalies

A

Choanal atresia, tracheoesophageal fistula, tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular ring, tracheal stenosis

40
Q

Tracheo-esophageal Fistula

A

Aspiration, drools, degree of severity – sick kids

41
Q

Congenital Syndromes

A

Pierre Robin Syndrome, Treacher Collin, Turner, Down’s, Goldenhar , Apert, Achondroplasia, Hallermann-Streiff, Crouzan

42
Q

Inflammatory

A

Epiglottitis, acute tonsillitis, peritonsillar abscess, retropharyngeal abscess, nasal congestion laryngotracheobronchitis, bacterial tracheitis, adenoidal hypertrophy, juvenile rheumatoid arthritis

43
Q

Traumatic/Foreign Body

A

burn, laceration, lymphatic/venous obstruction, fractures/dislocation, inhalational injury, postintubation croup (edema), swelling of uvula

44
Q

Metabolic

A

Congenital hypothyroidism, mucopolysaccharidosis, Beckwith-Wiedemann Syndrome, glycogen storage disease,

45
Q

Choanal Atresia

A

Complete nasal obstruction of the newborn
Occurs in 0.82/10 000 births
During inspiration, tongue pulled to palate, obstructs oral airway
Unilateral nare (right>left)
Bilateral choanal atresia is airway emergency
Death by asphyxia
Associated with other congenital defects

46
Q

Pierre Robin Syndrome

A

Occurs in 1/8500 births
Autosomal recessive
Mandibular hypoplasia, micrognathia, cleft palate, retraction of inferior dental arch, glossoptosis
Severe respiratory and feeding difficulties
Associated with OSA, otitis media, hearing loss, speech defect, ocular anomalies, cardiac defects, musculoskeletal (syndactyly, club feet), CNS delay, GU defects.

47
Q

Congenital Syndrome (Down’s Syndrome)

A

Trisomy 21
Occurs in 1/660 births
Short neck, microcephaly, small mouth with large protruding tongue, irregular dentition, flattened nose, and mental retardation
Associated with growth retardation, congenital heart disease, subglottic stenosis, tracheoesophageal fistula, duodenal atresia, chronic pulmonary infection, seizures, and acute lymphocytic leukemia
Atlantooccipital dislocation can occur during intubation due to congenital laxity of ligament

48
Q

Metabolic Beckwith - Wiedemann Syndrome

A

Occurs in 1/13000-15000 births
Chr 11p.15.5
Autosomal dominant
Macroglossia, Exomphalos, Gigantism, omphalocele
Associated with mental retardation, organomegaly, abdominal wall defect, pre- and postnatal overgrowth, neonatal hypoglycemia, earlobe pits, Wilms tumor

49
Q

Unexpected difficult airway algorithm

A
50
Q

Suspected difficult airway algorithm

A

Concepts 2 (11 decks)

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