Airway Management in Transport Toni Petrillo-Albarano, MD Pediatric Critical Care Medicine Children’s Healthcare of Atlanta at Egleston Children’s Hospital

Objectives b Overview of the differences between the pediatric and adult airway b Intubation of the pediatric patient

Anatomic Considerations in Pediatrics b b Relatively Large Occiput b b Large Tongue b b Larynx is anterior and superior b b Epiglottis may be floppy with acute angle b b Narrowest portion is cricoid cartilage

The Basics The airway in any patient can be: b b Physiologic maintained easily or with effort by the patient b b Maintainable with some assistance/positioning b b Invasive Intervention oral airway, nasal trumpet, or intubation

The Basics To assist patient’s in maintaining an airway: b b Clear mouth b b Position head b b Consider Airway adjuncts

Proper Positioning A jaw thrust or head tilt maneuver will position the tongue so that it will not obstruct the airway Remember that a child has a relatively large tongue compared to an adult In infants it is possible to hyperextend the neck too much and cause the soft tissue to obstruct the airway

Nasal Trumpet A nasal trumpet can be a useful adjunct possible for the trumpet to be too long or too short

Oral Airway An appropriately placed oral airway will pull the tongue forward and provide an unobstructed airway If the oral airway is too long, it will stimulate a gag. If it’s too short, it will not lift the tongue.

Airway Adjuncts The use of airway adjuncts, such as the nasal trumpet and oral airway, will only provide an adequate airway. The patient must have reasonable respiratory effort. If the patient is unable to maintain adequate ventilation, he/she should be bagged or proceed to endotracheal intubation.

Indications for Intubation Unable to protect airway 2. Inadequate ventilation 3. Hypoxemic respiratory failure requiring positive pressure 4. Therapeutic (e.g. Hyperventilation in head injury)

Difficult Airway Considerations b b Short, muscular neck b b Receding mandible b b Protruding incisors b b Uvula not visualized b b Limited TMJ mobility b b Limited C-spine mobility

What do you need? Monitors -- cardiac and pulse oximetry Suction -- Yankauer or catheter Machine -- ventilator or bag/mask Airway -- Endotracheal tube Intravenous -- peripheral or central line Drugs -- sedation/analgesia/paralysis/atropine

Laryngoscopes b b Straight b b Curved b b Fiberoptic

Proper visualization b b The laryngoscope should be used to lift “up and out”. Do not rock back on upper teeth. b b Curved blade tip is placed in vallecula and will lift epiglottis away from airway. b b Straight blade tip is used to hold the epiglottis from beneath.

Proper ETT Size Newborn - 6 months months - 1 year 4.0 > 1 year4 + age 4

Intubation Procedure b b Prepare Equipment b b Position patient Table height “Sniffing” position b b Pre-oxygenate 4 max breath in 30 sec 100% O2 for 3-5 min b b Induction agent sedative/analgesic b b Neuromuscular blocker b Intubation Laryngoscope in L hand Insert on R of mouth and sweep tongue to L Advance in midline until epiglottis visualized Advance tip of blade –into vallecula (curved blade) –beneath epiglottis (straight blade) Lift towards feet –“up and out”, “Never Lever”

Rapid Sequence Intubation b b Done when immediate airway stabilization is required or the patient has a “full stomach” has eaten-- pregnancy trauma-- abdominal mass GER-- misc bowel obstruction b b Expedited with rapid acting drugs and avoidance of bag mask ventilation

Rapid Sequence Intubation b b Procedure Pre-oxygenate Rapid Induction Agents Rapid Acting Neuromuscular Blocker Sellick’s Maneuver Intubate Check breath sounds, inflate cuff (if applicable) Release cricoid pressure

Sellicks’ Maneuver b b Cricoid Pressure b b Closes esophagus against the vertebral column b b protects against passive regurgitation b b DO NOT release until airway is secure !

Intubation Medications Goals: b b Provide adequate intubation conditions airway easily visualized patient comfort (not fighting procedure) b b Avoid complications hemodynamic instability ICP in head injury

Atropine b b Blunts vagal response that can cause bradycardia and dries oral secretions b b Dose = 0.02 mg/kg (min 0.1 mg) b b Adverse effects tachycardia mydriasis atropine flush disorientation

Benzodiazepines b b Effective in providing anxiolysis and amnesia b b Onset and duration vary between midazolam, lorazepam, and diazepam b b Dose = 0.1 mg/kg b b Adverse Effects include: hypotension and myocardial depression

Fentanyl b b Sedative/Analgesic b b Dose 2-5 mcg/kg b b Rapid Onset and short duration -- thus an excellent intubation med b b Virtually no CV side effects

Ketamine b b PCP Derivative, Dissociative Hypnotic b b Rapid Onset and short duration b b Dose = 1-2 mg/kg IV or 2-4 mg/kg IM b b Increases HR, and BP and thus may be ideal for the patient with shock. b b Increases cerebral metabolic rate and ICP and thus not a good choice in head injury or seizure

Thiopental (Pentothal) b b Dose = 2-5 mg/kg b b Max Effect in 60 seconds b b Sedative Hypnotic that decreases cerebral metabolic rate and ICP b b Hypotension and Myocardial Depression are possible adverse effects

Etomidate b Ultra short-acting non-barbiturate hypnotic b rapid induction of anesthesia with minimal cardiovascular effects b mg/kg over seconds b Peak effect: 1 minute b Duration of action: 3-5 minutes b Can cause adrenal suppression

Neuromuscular Blockers b b Recommend only rapid acting agents: Succinylcholine - dose = 1 mg/kg IV Rocuronium - dose = mg/kg IV Vecuronium - dose = mg/kg IV Mivacurium - dose = 0.2 mg/kg IV Atracurium - dose = 0.2 mg/kg IV

Recommended Intubation “Cocktails” b b Controlled Intubation Fentanyl & Lorazepam or Etomidate Vecuronium/Rocuronium + Atropine b b Head Injury Pentothal or Etomidate Lidocaine 1 mg/kg IV Vecuronium Atropine b Septic Shock Atropine Ketamine Rocuronium/Vecuronium b Status Asthmaticus Atropine Ketamine Lorazepam Rocuronium/Vecuronium

Physiologic Response to Intubation  Airway Reflexes LaryngospasmLaryngospasm CoughCough GagGag  Cardiovascular Reflexes Sinus bradycardia Tachycardia Hypertension Dysrhythmias

Assessing ETT placement b Direct visualization b ETCO 2 (digital readout or color paper) b Chest rise b Auscultation (be certain to confirm absence of gastric breath sounds) b ETT vapor (unreliable) b Chest X-ray

Monitoring on Transport  Physical Exam  EKG monitor  Pulse oximeter  E T CO 2 Monitor  Reevaluate Frequently

Capnograms Normal b Zero baseline b Rapid, sharp up rise b Alveolar plateau b Well-defined end-tidal b Rapid, sharp down stroke A—BDeadspace B—CDead space and alveolar gas C—DMostly alveolar gas DEnd-tidal point D—EInhalation of CO 2 free gas

Capnography Sudden loss of waveform b Esophageal intubation b Ventilator disconnect b Ventilator malfunction b Obstructed / kinked ETT

Capnography Decrease in waveform b Sudden hypotension b Massive blood loss b Cardiac arrest b Hypothermia b PE b CPB

Capnography Gradual increase in waveform b Increased body temp b Hypoventilation b Partial airway obstruction b Exogenous CO 2 source (w/laparoscopy/CO 2 inflation)

Capnography Sudden drop – not to zero b Leak in system b Partial disconnect of system b Partial airway obstruction b ETT in hypopharynx

Capnography Sustained low EtCO 2 b Asthma b PE b Pneumonia b Hypovolemia b Hyperventilation Low ETCO 2, but good plateau

Capnography Cleft in alveolar plateau b Partial recovery from neuromuscular blockade 40

Capnography Transient rise in ETCO 2 b Injection of bicarbonate b Release of limb tourniquet 40

Capnography Sudden rise in baseline b Contamination of the optical bench – need to recalibrate 40

Questions b 1. Which drug is not used in the intubation of a head injury patient? A. KetamineA. Ketamine B. ThiopentalB. Thiopental C. LidocaineC. Lidocaine D. EtomidateD. Etomidate

Question b 2.Capnograph represents b A. Esophageal intubation b B. Ventilator disconnect b C. Obstructed / kinked ETT b D. All of the above

Question b 3. Appropriate ETT size for a 6 year old calculated by formula is? A. 6.0A. 6.0 B. 4.5B. 4.5 C. 5.0C. 5.0 D. 5.5D. 5.5

Question b 4. True or False: Curved blade tip is placed in vallecula and will lift epiglottis away from airway

Question b 5. All of the following are indications for intubation except: A.A. Unable to protect airway B.B. Inadequate ventilation C.C. Hypoxemic respiratory failure requiring positive pressure D. GCS 10D. GCS 10