Pediatric Airway Management SNOHOMISH COUNTY EMS

OBJECTIVES Anatomy Anatomy Physiology Physiology Equipment Equipment Establish respiratory distress present Establish respiratory distress present Technique Technique Post intubation management Post intubation management Pitfalls and Pearls Pitfalls and Pearls Difficult airway Difficult airway

ANATOMY Unique <2 years old Unique <2 years old Approaches normal adult airway by 8 years old Approaches normal adult airway by 8 years old Glottic opening high and anterior Glottic opening high and anterior C1, transitions to C3/4, then C5/6 by adulthood C1, transitions to C3/4, then C5/6 by adulthood More soft tissue, less tone More soft tissue, less tone

Consider copying fig 20-2 p 270 here

ANATOMY Large tongue in relation to oral cavity Large tongue in relation to oral cavity Large tonsils and adenoids that can bleed (no blind nasotracheal intubations) Large tonsils and adenoids that can bleed (no blind nasotracheal intubations) Angle of epiglottis to laryngeal opening more acute Angle of epiglottis to laryngeal opening more acute

ANATOMY Large occiput/cranium flexes the neck Large occiput/cranium flexes the neck Avoid further neck flexion Avoid further neck flexion Use sniffing position Use sniffing position Neck flexed, head extended Neck flexed, head extended

ANATOMY Small cricothyroid membrane Small cricothyroid membrane <3-4 years old almost nonexistant <3-4 years old almost nonexistant >8 similar to adults >8 similar to adults No surgical cricothyroidotomy <8 No surgical cricothyroidotomy <8 Cricoid ring most narrow part of airway (below vocal cords) Cricoid ring most narrow part of airway (below vocal cords)

PHYSIOLOGY Smaller floppy upper airway more likely to obstruct and more susceptible to swelling Smaller floppy upper airway more likely to obstruct and more susceptible to swelling Resistance is inversely proportional to radius Resistance is inversely proportional to radius R  1/r4th power R  1/r4th power Small decrease in airway size=large increase in airway resistance Small decrease in airway size=large increase in airway resistance

PHYSIOLOGY Crying increases the work of breathing 32 times Crying increases the work of breathing 32 times Basal O2 requirement 2x that of adults Basal O2 requirement 2x that of adults FRC (functional residual capacity) 40% of adults FRC (functional residual capacity) 40% of adults Only half the alveoli of adults Only half the alveoli of adults Overall, less reserve and faster desaturations Overall, less reserve and faster desaturations

EQUIPMENT Length based systems Length based systems Decrease errors Decrease errors Eliminate remembering and completing mathematical equations Eliminate remembering and completing mathematical equations Organize equipment Organize equipment

BROSELOW SYSTEM

EQUIPMENT Self inflating bags smallest 450ml Self inflating bags smallest 450ml Pop off valves that may have to be closed Pop off valves that may have to be closed Newborn equipment different than peds (0 blades, <50mm oral airways, 250ml BVM, 3-0 tubes) Newborn equipment different than peds (0 blades, <50mm oral airways, 250ml BVM, 3-0 tubes)

RESPIRATORY DISTRESS Rapid 30 second assessment Rapid 30 second assessment T one T one I nteractive I nteractive C onsolablity C onsolablity L ook/track L ook/track S peech/cry S peech/cry

RESPIRATORY DISTRESS Altered mental status Altered mental status Nasal flaring Nasal flaring Head bobbing Head bobbing Accessory muscle use Accessory muscle use Grunting Grunting

RESPIRATORY DISTRESS You must undress the patient You must undress the patient Retractions Retractions Substernal Substernal Intercostal Intercostal Supraclavicular Supraclavicular Suprasternal Suprasternal

RESPIRATORY DISTRESS Infants are nose breathers Infants are nose breathers Secretions can impeded air flow Secretions can impeded air flow Bulb syringe nasal suction may alleviate this Bulb syringe nasal suction may alleviate this

RESPIRATORY FAILURE Impending respiratory arrest Impending respiratory arrest All of the above signs diminish All of the above signs diminish Respiratory rate diminishes Respiratory rate diminishes Mental status diminishes Mental status diminishes Child becomes quiet Child becomes quiet Mottling may develop Mottling may develop

TECHNIQUE MEDICATIONS Succinylcholine Succinylcholine Dose higher at 1.5mg/kg Dose higher at 1.5mg/kg Etomidate Etomidate 0.3mg/kg 0.3mg/kg Fentanyl Fentanyl 1-3mcg/kg consider for age >10 and head injury 1-3mcg/kg consider for age >10 and head injury

TECHNIQUE MEDICATIONS Vecuronium Vecuronium 0.1mg/kg 0.1mg/kg Rocuronium Rocuronium 1mg/kg 1mg/kg

TECHNIQUE MEDICATIONS Atropine Atropine Routine use not recommended Routine use not recommended Should be available and prepared in case it is needed (more common in children <1) Should be available and prepared in case it is needed (more common in children <1) 0.02mg/kg 0.02mg/kg

TECHNIQUE HEAD POSITION Sniffing position Sniffing position Slight anterior displacement of neck (pulling chin up) Slight anterior displacement of neck (pulling chin up) Small infants may require elevation of shoulders with a towel to counteract a large occiput flexing head Small infants may require elevation of shoulders with a towel to counteract a large occiput flexing head Older children may require a towel under the head Older children may require a towel under the head Goal is to align ear canal anterior to shoulders Goal is to align ear canal anterior to shoulders Head tilt chin lift or Jaw thrust (trauma patients) Head tilt chin lift or Jaw thrust (trauma patients)

Picture Fig 21-1 page 284

TECHNIQUE OXYGEN SUPPLEMTATION Oxygen may be delivered by Oxygen may be delivered by Blow by Blow by Nasal cannula Nasal cannula Face mask Face mask Forcing the child to struggle with nasal cannula oxygen increase oxygen demand Forcing the child to struggle with nasal cannula oxygen increase oxygen demand Blow by may suffice Blow by may suffice

TECHNIQUE BVM BVM alone may suffice for short transports BVM alone may suffice for short transports Pediatric airway obstruction usually amenable to BVM Pediatric airway obstruction usually amenable to BVM The extra thoracic trachea is collapsible in children, so with increased negative pressure from inspiration during obstruction, obstruction may become worse and BVM may help The extra thoracic trachea is collapsible in children, so with increased negative pressure from inspiration during obstruction, obstruction may become worse and BVM may help

TECHNIQUE BVM Don ’ t compress submental tissue Don ’ t compress submental tissue Hold angle of mandible Hold angle of mandible Use C-Clamp technique (solo) Use C-Clamp technique (solo) Use 2 providers when possible Use 2 providers when possible Don ’ t put pressure on eyes (causes vagal response) Don ’ t put pressure on eyes (causes vagal response)

TECHNIQUE BVM Normal tidal volume 8-10ml/kg Normal tidal volume 8-10ml/kg Watch for adequate chest rise Watch for adequate chest rise Squeeze-Release-Release to allow for exhalation Squeeze-Release-Release to allow for exhalation Only use enough force to see chest rise Only use enough force to see chest rise 8-10 BPM code, alive (monitor end tidal CO2) 8-10 BPM code, alive (monitor end tidal CO2)

TECHNIQUE BVM Avoid gastric insufflation Avoid gastric insufflation Avoid excessive peak inspiratory pressure Avoid excessive peak inspiratory pressure Ventilate slowly and watch for chest rise Ventilate slowly and watch for chest rise Slight cricoid pressure (excessive will compress trachea in peds) Slight cricoid pressure (excessive will compress trachea in peds)

TECHNIQUE BLADES Follow Broselow guide Follow Broselow guide Miller straight blade better until about age 5 Miller straight blade better until about age 5 Lifts disproportionately large epiglottis out of way Lifts disproportionately large epiglottis out of way

TECHNIQUE CRICOID PRESSURE Insufficient evidence to routinely recommend cricoid pressure during intubation (as opposed to BVM) Insufficient evidence to routinely recommend cricoid pressure during intubation (as opposed to BVM)

TECHNIQUE LAYNGEAL MANIPULATION Use as needed Use as needed Frequently: Frequently: B ackward B ackward U pward U pward R ightward R ightward P ressure P ressure

TECHNIQUE TUBES Use Broselow guide Use Broselow guide Be prepared with tubes 0.5mm larger and smaller Be prepared with tubes 0.5mm larger and smaller Narrowest part of airway is below cords Narrowest part of airway is below cords If tight, use smaller tube If tight, use smaller tube If large air leak, use larger tube or same size tube with cuff If large air leak, use larger tube or same size tube with cuff Small air leak, no worries if adequate chest rise, O2 sat, end tidal CO2 Small air leak, no worries if adequate chest rise, O2 sat, end tidal CO2

TECHNIQUE TUBES Cuffed tubes Cuffed tubes Are OK Are OK Cuff pressure needs to be monitored (20-25cm water) Cuff pressure needs to be monitored (20-25cm water) Don ’ t have to be inflated Don ’ t have to be inflated In general, go a size smaller if using cuffed tube for size <6.0 In general, go a size smaller if using cuffed tube for size <6.0 Too large a tube/too high cuff pressure)=laryngeal tracheal stenosis which can develop rapidly Too large a tube/too high cuff pressure)=laryngeal tracheal stenosis which can develop rapidly

TECHNIQUE TUBES Tube insertion depth Tube insertion depth Follow Broselow Follow Broselow 3x size of tube (4.0 ETT=12cm insertion length at teeth) 3x size of tube (4.0 ETT=12cm insertion length at teeth) Secure tube, immobilize neck, as short trachea predisposes to moving tube too far in with neck flexion, and out with neck extension Secure tube, immobilize neck, as short trachea predisposes to moving tube too far in with neck flexion, and out with neck extension

TECHNIQUE CONFIRM PLACEMENT Tube fogging Tube fogging B/L breath sounds B/L breath sounds Silent epigastrum Silent epigastrum End Tidal CO2 End Tidal CO2 Pulse ox Pulse ox

TECHNIQUE END TIDAL CO2 Peds detectors up to 15kg (adult detectors have too much dead space in circuit) Peds detectors up to 15kg (adult detectors have too much dead space in circuit) Adult detectors over 15kg (peds detectors will cause too much resistance Adult detectors over 15kg (peds detectors will cause too much resistance

TECHNIQUE END TIDAL CO2 In cardiac arrest: In cardiac arrest: If <10-15mmHg, focus on improving CPR and avoid over ventilation If <10-15mmHg, focus on improving CPR and avoid over ventilation An abrupt and sustained increase may signal return of spontaneous circulation An abrupt and sustained increase may signal return of spontaneous circulation In non arrest: In non arrest: Titrate to clinical condition (35-45 unless head injury/impending herniation 25-30) Titrate to clinical condition (35-45 unless head injury/impending herniation 25-30)

POST INTUBATION MANAGEMENT Adequate sedation Adequate sedation Benzodiazepines Benzodiazepines Diazepam 0.2mg/kg (max 10mg/dose) Diazepam 0.2mg/kg (max 10mg/dose) Lorazepam 0.05mg/kg (max 2mg/dose) Lorazepam 0.05mg/kg (max 2mg/dose) Midazolam 0.1mg/kg (max 2mg/dose) Midazolam 0.1mg/kg (max 2mg/dose) Opiates Opiates Fentanyl 1-3mcg/kg (max 50mcg/dose) Fentanyl 1-3mcg/kg (max 50mcg/dose) Morphine mg/kg (max 5mg/dose) Morphine mg/kg (max 5mg/dose) Paralytics as needed Paralytics as needed Rocuronium 1mg/kg Rocuronium 1mg/kg Vecuronium 0.1mg/kg Vecuronium 0.1mg/kg

POST INTUBATION MANAGEMENT Problems Problems D isplacement of tube (confirm placement) D isplacement of tube (confirm placement) O obstruction of tube (pass suction catheter) O obstruction of tube (pass suction catheter) P neumothorax P neumothorax E quipment failure (unhook from vent, check O2) E quipment failure (unhook from vent, check O2)

PITFALLS AND PEARLS Performance anxiety Performance anxiety Equipment stocking and testing Equipment stocking and testing Troubleshooting Troubleshooting Periodic training and practice Periodic training and practice

DIFFICULT AIRWAY Infectious disease causes Infectious disease causes Noninfectious causes including trauma Noninfectious causes including trauma Congenital abnormalities Congenital abnormalities

DIFFICULT AIRWAY INFECTIOUS DISEASE Epiglottitis Epiglottitis Croup Croup Retropharyngeal abscess Retropharyngeal abscess Bacterial Tracheitis Bacterial Tracheitis Ludwig ’ s angina Ludwig ’ s angina

DIFFICULT AIRWAY INFECTIOUS DISEASE Small changes in airway diameter have a large impact on airway resistance Small changes in airway diameter have a large impact on airway resistance Crying increases work of breathing 32 times Crying increases work of breathing 32 times Don ’ t “ over treat ” Don ’ t “ over treat ”

EPIGLOTTITIS If stable, leave patient with parent in position of comfort If stable, leave patient with parent in position of comfort 2 person bag valve mask ventilation can be sufficient 2 person bag valve mask ventilation can be sufficient If needed, intubation can be attempted with a smaller than predicted tube If needed, intubation can be attempted with a smaller than predicted tube Push on chest to try to see bubbles coming from airway if visualization obstructed Push on chest to try to see bubbles coming from airway if visualization obstructed One of the few indications for needle cricothyrotomy if all else fails One of the few indications for needle cricothyrotomy if all else fails

CROUP Subglottic narrowing Subglottic narrowing Tube may fit through cords, but then get snug Tube may fit through cords, but then get snug Use smaller than expected tube Use smaller than expected tube BVM can work, but requires 2 people and possible high pressure BVM can work, but requires 2 people and possible high pressure

DIFFICULT AIRWAY NONINFECTIOUS DISEASE Foreign body Foreign body Burns Burns Anaphylaxis Anaphylaxis Caustic ingestion Caustic ingestion Trauma Trauma

FOREIGN BODY Conscious Conscious Consider doing nothing if patient stable Consider doing nothing if patient stable Back blows less than age 1 year Back blows less than age 1 year Heimlich (age greater than 1) Heimlich (age greater than 1) Unconscious Unconscious BVM may work BVM may work Direct laryngoscopy Direct laryngoscopy Removal of object Removal of object Push it down and move the tube back to normal position Push it down and move the tube back to normal position Needle cricothyrotomy will only work if obstruction is above the cricothyrotomy level (you should see it but can ’ t remove it) Needle cricothyrotomy will only work if obstruction is above the cricothyrotomy level (you should see it but can ’ t remove it)

BURNS, ANAPHYLAXIS, CAUSTIC INGESTIONS, TRAUMA If condition is decompensating and/or not responding to treatment, consider early intervention If condition is decompensating and/or not responding to treatment, consider early intervention Should consider medications first in anaphylaxis Should consider medications first in anaphylaxis

CONGENITAL ABNORMALITITES Don ’ t try unless you have to Don ’ t try unless you have to May be more reasonable to support until respiratory failure/arrest has occurred May be more reasonable to support until respiratory failure/arrest has occurred Treat for causes of respiratory distress Treat for causes of respiratory distress

CONGENITAL ABNORMALITITES MICROGNATHIA Small mandible reduces the space to which the tongue and soft tissue can be displaced out of your way Small mandible reduces the space to which the tongue and soft tissue can be displaced out of your way

DIFFICULT AIRWAY ADJUNCTS LMA LMA Needle cricothyrotomy Needle cricothyrotomy Combitube/King LT Combitube/King LT

DIFFICULT AIRWAY LMA Can be used in all ages Can be used in all ages In small infants more complications In small infants more complications Causes obstruction with relatively large epiglottis Causes obstruction with relatively large epiglottis Easy to lose adequate seal with movement Easy to lose adequate seal with movement Air leaks Air leaks Recommend inserting upside down and rotating it as advanced back Recommend inserting upside down and rotating it as advanced back Not for foreign bodies, caustics, burns Not for foreign bodies, caustics, burns

NEEDLE CRICOTHYROTOMY For use when you cant intubate or ventilate For use when you cant intubate or ventilate For use in children <8-10 years old For use in children <8-10 years old Not helpful for croup or distal foreign bodies Not helpful for croup or distal foreign bodies

NEEDLE CRICOTHYROTOMY Extend head, towel under shoulders Extend head, towel under shoulders Identify landmarks Identify landmarks Insert catheter (14g) over the needle at a 30 degree angle directed toward feet Insert catheter (14g) over the needle at a 30 degree angle directed toward feet Aspirate air Aspirate air Slide catheter off needle and remove needle Slide catheter off needle and remove needle Attach 3mm ETT adapter and begin BV Attach 3mm ETT adapter and begin BV

NEEDLE CRICOTHYROTOMY Will require excessive force due to small catheter diameter Will require excessive force due to small catheter diameter Pop off valve should be disabled Pop off valve should be disabled Does not protect airway Does not protect airway Does not allow for adequate ventilation, only oxygenation Does not allow for adequate ventilation, only oxygenation

NEEDLE CRICOTHYROTOMY Complications Complications Inappropriate needle placement Inappropriate needle placement Inadequate ventilation (hypercarbia and acidosis) Inadequate ventilation (hypercarbia and acidosis) Obstruction of small catheter Obstruction of small catheter Subcutaneous emphysema Subcutaneous emphysema

NEEDLE CRICOTHYROTOMY TTV TTV For use >5 years For use >5 years Supraglottic patency required to allow for exhalation (air stacking) Supraglottic patency required to allow for exhalation (air stacking) Barotrauma Barotrauma Start with 20 PSI and adjust to chest rise Start with 20 PSI and adjust to chest rise Requires no more than of 1 second inspiration, then 3 seconds to exhale Requires no more than of 1 second inspiration, then 3 seconds to exhale Nasal/oral airway should be placed as well Nasal/oral airway should be placed as well

COMBITUBE/KING LT Double/single lumen tube designed to be place in esophagus Double/single lumen tube designed to be place in esophagus Must be 4ft tall for small Combitube Must be 4ft tall for small Combitube May not protect against aspiration May not protect against aspiration Not for caustic ingestion or significant esophageal pathology Not for caustic ingestion or significant esophageal pathology