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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
pedi anesthesia equipment: oral airway
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
pedi nasal airway
Nasal Airway Avoid In Children Due To Risk Of Injuring Large Adenoids During Placement, Causing Bleeding
27
pedi laryngoscope blades
- 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
pedi ETT
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
pedi ETT distance assessment
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
pedi case with URI
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
URI S&S
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
URI anesthesia and intraop management
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
Pedi Thoracic Pathology: Infants and Neonates
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
Pedi thoracic Pathology: childhood
Childhood: Tumors (lymphoma, neuroblastoma, metastatic) Empyema Pectus Excavatum = concaved chest Scoliosis Congenital branchial cleft cyst
35
Pedi anesthesia management
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
OLV and children
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
Pedi post-op analgesia
- 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
Congenital Neck Masses
Dermoid cysts, cystic teratomas, cystic hygroma, lymphangiomas, neurofibroma, lymphoma, hemangioma
39
Congenital Anomalies
Choanal atresia, tracheoesophageal fistula, tracheomalacia, laryngomalacia, laryngeal stenosis, laryngeal web, vascular ring, tracheal stenosis
40
Tracheo-esophageal Fistula
Aspiration, drools, degree of severity -- sick kids
41
Congenital Syndromes
Pierre Robin Syndrome, Treacher Collin, Turner, Down’s, Goldenhar , Apert, Achondroplasia, Hallermann-Streiff, Crouzan
42
Inflammatory
Epiglottitis, acute tonsillitis, peritonsillar abscess, retropharyngeal abscess, nasal congestion laryngotracheobronchitis, bacterial tracheitis, adenoidal hypertrophy, juvenile rheumatoid arthritis
43
Traumatic/Foreign Body
burn, laceration, lymphatic/venous obstruction, fractures/dislocation, inhalational injury, postintubation croup (edema), swelling of uvula
44
Metabolic
Congenital hypothyroidism, mucopolysaccharidosis, Beckwith-Wiedemann Syndrome, glycogen storage disease,
45
Choanal Atresia
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
Pierre Robin Syndrome
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
Congenital Syndrome (Down’s Syndrome)
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
Metabolic Beckwith - Wiedemann Syndrome
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
Unexpected difficult airway algorithm
50
Suspected difficult airway algorithm

Concepts 2 (11 decks)

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