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N934 Advanced Principles of Anesthesia II > Peds Difficult Airway > Flashcards

Peds Difficult Airway Flashcards

1
Q

difficult peds airway

A

-less common than adults
-prep for known difficult airway is different
-predictors for adults often do not apply to kids
-awake intubation not an option for kids
-shift from uncuffed to cuffed ETT
shift from fiberoptic scopes to various video laryngoscopes

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2
Q

peds airway tongue

A
  • large in proportion to rest of oral cavity
  • easy obstruction of infant airway
  • oral airway can relieve the obstruction
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3
Q

peds airway differences

A
  • narrow nasal passages
  • increased salivary secretions
  • larger tonsils and adenoids
  • prominent occiput (use a dang shoulder roll)
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4
Q

peds position of the larynx

A
  • higher (more cephalad) for neonates to 2 years of age
  • larynx seems more anterior with acute angle
  • C3-4 (adult it is C4-5)
  • a straight laryngoscope blade more effectively lifts tongue from view
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5
Q

peds epiglottis

A
  • adult epiglottis is flat and broad
  • infant epiglottis is narrower, omega shaped, and angled away from the axis of the trachea
  • often will obstruct view of the vocal cords
  • more difficult to lift
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6
Q

peds vocal cords

A
  • adult vocal cords axis is perpendicular to the trachea
  • infant vocal cords have a lower (more caudad) attachment anteriorly vs posteriorly
  • can lead to difficult intubation with the tip of the ETT held up at the anterior portion of the cords/folds
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7
Q

peds trachea

A
  • shorter than the adult trachea

- infant 4-5 cm vs adult 10-12 cm

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8
Q

formula for ETT depth in kids

A

3x ETT size

usually a good rule of thumb but obvs still confirm in other ways

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9
Q

peds subglottic area

A
  • narrowest portion of the child’s larynx is cricoid cartilage (until around age 8)
  • when too large ETT is inserted, it may go through the cords but get stuck subglottic or in the cricoid region
  • funnel vs elliptical shape (anterior posterior dimension is greater than the transverse)
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10
Q

what happens if a tight fitting tube is placed in a peds patient?

A
  • compression of tracheal mucosa
  • cause edema and reduce the luminal diameter and result in post extubation croup
  • because the subglottic region in the infant is smaller than the adult, the same degree of airway edema will result in greater resistance to airflow in the infant (remember Poisoulle’s law)
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11
Q

peds airway evaluation

A
  • mallampati (mouth opening) and mandible
  • history of a syndrome/congenital anomalies or physical findings
  • loose or missing teeth
  • recent respiratory infections
  • assess WOB
  • snoring/noisy breathing at night
  • baseline O2 sats
  • asthma/smoking or second hand exposure
  • global appearance
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12
Q

evidence of airway obstruction in peds

A
  • tracheal tug
  • paradoxical chest wall movement
  • absence of movement in ambu bag
  • no ETCO2
  • most frequent mistake in peds is late recognition of upper airway obstruction
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13
Q

signs of inadequate sedation depth

A
  • struggle
  • breath hold
  • partial airway obstruction
  • rapid desat
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14
Q

signs of overly aggressive bag mask ventilation

A
  • gastric insufflation
  • reduced lung volumes
  • increased risk of regurgitation
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15
Q

predicting the difficult peds airway

A
  • highest incidence in infants (esp premies), craniofacial anomalies, and congenital cardiac anomalies
  • may improve with age, with exception of Goldenhar and mucopolysaccharidoses
  • mallampati correlates with cormack-lehane view
  • observe child’s profile and look for recessed or smaller mandible, limited mouth opening, prominent dentition, facial asymmetry and cleft palate
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16
Q

syndromes/conditions associated with peds difficult airway

A
  • Goldenhar
  • pierre robin
  • treacher collins
  • apert
  • trisomy 21
  • juvenile arthritis
  • cleft palate
  • trauma/burns
  • oral tumor
  • kippel-feil
  • muccopolysaccharidosis
17
Q

preparation for difficult airway

A
  • difficult airway cart - blades, LMAs, ETTs, oral/nasal airways, fiberoptic, video scopes
  • IV access (or IO)
  • experienced assistance
  • sedation options
  • plans ABC
  • communication with otolaryngologist and other anesthesia providers in advance
18
Q

induction strategies for difficult peds airway

A
  • maintain spontaneous respirations as long as possible whenever possible
  • delay PPV and muscle relaxation
  • NP airway or small ETT in nasopharynx can act as oxygen conduit during intubation attempts
  • cautious titration with combination of propofol, ketamine, dex, midaz, remi, etc…
19
Q

infant sniffing position

A
  • chin plane horizontally aligned
  • neck wide and open
  • external auditory meatus and suprasternal notch horizontally aligned
  • use shoulder roll and potentially head rest
20
Q

DVL peds tips

A
  • size based on size of patient’s mandible rather than age/weight (like an oral airway)
  • straight blade will often give best view in micrognatic or retrognathic patients
  • insert on extreme right
  • may be helpful to have assistant pull R corner of kids mouth
  • styletted ETT - DO NOT ADVANCE stylet through cords bc it may damage trachea
21
Q

suppraglottic airways peds

A
  • not useful when obstruction beyond glottis, require high vent pressure, or those at risk for aspiration
  • not a secure airway
  • useful as conduit for fiberoptic ETT intubation
  • different types –> LMA classic, air-Q
22
Q

video laryngoscopes peds

A
  • increasing number of designs available for peds
  • consider ETT insertion on R side of mouth before scope insertion due to rapid desaturation of peds
  • stylet in shape of blade
  • create as much viewing space between tip and vocal cords
  • insertion technique = midline
  • may also be used with flexible fiberoptic intubation (both together)
23
Q

flexible fiberoptic scope peds

A
  • used with other devices
  • ensure adequate oxygenation bc no port for this on peds sizes
  • MAKE SURE you load ETT onto scope before inserting
  • hold scope at level where tip will be at the vocal cords (roughly angle of manidble; index finger and thumb grasp the scope at the point where the fingers touch the patient lips/nose
  • direct scope midline with anterior flexion at the tip
24
Q

unanticipated peds difficult airway

A
  • act quickly/calmly
  • call for experienced help
  • BVM easy or spontaneously breathing = reverse and awaken child
  • do not repeat same thing over and over
  • consider LMA to temporize and improve oxygenation
  • BVM not adequate –> HELP including ENT, anesthesia, ECMO
25
Q

peds cannot intubate/ventilate situation

A
  • 2 hand BVM
  • LMA
  • emergency invasive/surgical access (cric, rigid bronch, surgical trach)
26
Q

cricothyroidotomy supplies

A
  • syringe half filled with saline
  • IV catheter
  • 15-mm adapter from ETT

N934 Advanced Principles of Anesthesia II (17 decks)

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