Pulmonary Flashcards
How should you size an ET tube in croup or another etiology of upper airway narrowing?
Use an uncuffed tube, size 0.5mm smaller than you would standardly use. Formula is (age/4)+4
What is hsv gingivostomatitis and why is it important in croup?
Hsv mouth infection.
Could be a sign that patient has a disseminated vs airway hsv infection
Describe important anatomical differences in the pediatric airway.
- Larynx-funnel shaped and has a higher cervical position the younger the age
- Epiglottis and trachea-floppier and without as much cartilage. The trachea is shorter leading to increased incidence of tube dislodgements or mainstem intubations.
Describe important physiological considerations for pediatric respiratory distress.
- preferential nasal breathers-suction the nose of infants as this is 50% of their airway resistance
- lower tidal volumes-sump into the stomach is important to prevent mechanical obstruction
- higher O2 metabolism-kids crash quicker when in respiratory distress
- higher vagal tones-more likely to have bradycardia during intubation
What positioning should be used in a pediatric patient having respiratory distress?
- No sniffing position! Can worsen airway view
- Align earlobe to sternal notch and have patient’s face parallel to the ceiling, place a shoulder roll under an infant
Describe the sizing of the nasal trumpet and in which scenarios it is contraindicated in.
- Nostril-tragus
- Contraindicated in basilar skull fracture, evidence of CSF leak, cribriform plate fracture, coagulopathy
What is the best indicator of successful bag valve mask ventilation?
Visualizing chest rise!
What rates should you bag at for newborns, infants, and toddler and older?
- Newborn=30 breaths per minute “squeeze release, squeeze release”
- Infant=20 breaths per minute
- Toddler and up=10 breaths per minute “squeeze release release, squeeze release release”
What is a common complication with over aggressive bagging?
pneumothorax
Give a differential diagnosis to consider in the child with croup.
-foreign body, retrophayngeal abscess, peritonsillar abscess, bacterial tracheitis, subglottic stenosis, infectious mononucleosis
What are diagnoses that often require NIPPV in neonates/infants and older children?
- neonates and infants-weaning off vent, prevent lung collapse, pt has respiratory drive but needs support
- Older kids-impending respiratory muscle fatigue, asthma, bronchiolitis, pneumonia, OSA, myopathies, CF, chronic lung disease
What are contraindications to beginning NIPPV?
Apnea/pt without respiratory drive, severe facial burn, altered consciousness, inability to protect airway, airway surgery, air leak syndrome (pneumothorax or pneumomediastinum), uncooperative
What are modes of NIPPV?
CPAP, BiPAP, NIPPV
What are potential complications of beginning NIPPV?
- stomach distension–>increased intrathoracic pressure–>decreased preload–>cardiac arrest (place an sump!)
- skin ulceration and eye irritation
Give some indications to intubate
- Cardiac arrest, GCS<8, decreasing level of consciousness, increased ICP, combative and need for trauma eval
- Respiratory arrest/impending respiratory failure/need for prolonged airway-reduced airway entry, severe work of breathing, cyanosis despite O2, irregular breathing/apnea
How do you size ET tubes and when should you use uncuffed tubes?
- (age/4)+4 (+3.5 for cuffed tube)
- infants-full term=3.5, preemie=GA/10
- Use uncuffed tubes in newborns/preemies or kids with upper airway narrowing
How do you estimate the insertion depth of the ETT?
depth=3xETT size
When do you use straight vs curved blades and how do you size the blades for intubation?
- Straight (Miller) blade-<2yo
- Curved (Macintosh) blade->/=2yo
- blade size 0=preemie
- blade size 1=newborn-2yo
- blade size 2=3yo-12yo
- blade size 3=>12yo
What is the goal of giving medications during rapid sequence intubation?
You want to keep the patient safely and comfortably paralyzed while avoiding the complications of bradycardia and increased intracranial pressure
When should you consider using atropine during rapid sequence intubation? What is the dose of atropine?
- any child <1yo as they have high vagal tones
- any child <5yo who requires the use of succinylcholine
- anyone who has received multiple doses of succinylcholine
- any child suspected to be in septic shock or late stage hypovolemic shock
- 0.02mg/kg, max 1mg
Give examples of sedatives used in the following circumstances:
- hemodynamically stable, w/out other complicating clinical features
- hypotension other than septic shock
- septic shock
- increased ICP
- hypotension with head injury
- status asthmaticus
- status epilepticus
- hemodynamically stable, w/out other complicating clinical features-etomidate
- hypotension other than septic shock-etomidate
- septic shock-ketamine, use etomidate if ketamine contraindicated
- increased ICP-etomidate, if hemodynamically stable can use propofol
- hypotension with head injury-etomidate
- status asthmaticus-ketamine or etomidate
- status epilepticus-if hemodynamically stable use versed or propofol, if hypotensive use etomidate
- Under what circumstances should you consider pre-treating a patient with fentanyl prior to intubation?
- When should you avoid pretreating with fentanyl?
- What is the dose of fentanyl in this situation?
- increased intracranial pressure (meningitis, encephalitis, severe traumatic brain injury, or cerebral edema) with normal to elevated blood pressures who will be sedated with etomidate
- do not give if the patient has soft BPs.
- IV fentanyl 1-3mcg/kg/dose given about 3 minutes before sedative medication is to be given
Give contraindications to using succinylcholine for paralysis during RSI.
- Chronic myopathy or denervating neuromuscular disease
- 48 to 72 hours after burns, multiple trauma, or an acute denervating event
- Extensive crush injury
- History of malignant hyperthermia
- Preexisting hyperkalemia
- increased ICP
- increased intraocular pressure
- organophosphate poisoning
In what order are sedatives and paralytics given during rapid sequence intubation?
Give the sedative first followed rapidly by the paralytic as soon as the child becomes unconscious