Download presentation
Presentation is loading. Please wait.
1
Paediatric Airway Emergencies
DR. D. Mannion. Chairman Dept of Anaesthesia & Critical Care OLCH Crumlin 9/21/2018 IARNA 2010
2
Objectives Why are children different?
Anatomy Physiology Routine management of paediatric airway Common problems Management of difficult airway. Anticipated Unanticipated 9/21/2018 IARNA 2010
3
ANATOMY Supra Glottic Narrow nares Large tongue
Epiglottis large and floppy Larynx more anterior Larynx more cephalad C3 – C4 Sub Glottic Narrow cricoid ring Trachea 2-5 cm short Bronchi more horizontal Small cricothyroid membrane Mobile compliant trachea 9/21/2018 IARNA 2010
4
PHYSIOLOGY Lung volume smaller in proportion
Metabolic rate is twice an adults Greater VO2 6ml/kg v 3 ml/kg in adult Vent requirement per unit lung is greater Airway resistance is greater due to small airways High respiratory rates 9/21/2018 IARNA 2010
5
Physiology – practical implications
Great for inhalational inductions Great for maintaining inhalational anaesthesia BUT If airway obstructed they rapidly desaturate. 9/21/2018 IARNA 2010
6
Also Neonates obligate nasal breathers until 2-5 months of age.
Tonsils and adenoids appear at 2 years and reach max size at 4 – 7 years. Snoring, sleep apnoea and upper airway obstruction when unconscious. 9/21/2018 IARNA 2010
7
COMMON DIFICULTIES Position Mask
Neutral position – small role under shoulders Over extended neck worsens obstruction Mask Shouldn’t occlude nostrils, pressure on eyes Chin Lift Pressure on submental tissues occludes airway as tongue is pushed up into palate. Jaw thrust – most effective manouvere 9/21/2018 IARNA 2010
8
LARYNGOSCOPY Straight blade picks up epiglottis
Mobile larynx means cricoid pressure can considerably improve the view. Vocal cords angled – anterior commisure may hitch tracheal tube – rotate it. Most ET tubes are marked with black line to indicate how far to insert. 9/21/2018 IARNA 2010
9
Microlaryngoscopy Inhalational technique IV anaesthesia technique
9/21/2018 IARNA 2010
10
Common problems Laryngospasm UAO Laryngeal obstruction Foreign body
Epiglottitis/Papillomatosis/Vocal cord palsy Foreign body Sub glottic oedema/ Tracheomalacia Mediastinal mass Difficult intubation 9/21/2018 IARNA 2010
11
Upper airway obstruction
Laryngomalacia – commonest congenital stridor 9/21/2018 IARNA 2010
12
Laryngomalacia Presents 2 weeks Stridor feeding difficulties
Gone by 18 – 24 months 9/21/2018 IARNA 2010
13
Laryngospasm BCH experience 210 cases over 6 years
Inadequate depth of anaesthesia usual factor Commonest < 6 years and < 1 yr Experience of anaesthetist influenced occurence 9/21/2018 IARNA 2010
14
Laryngospasm - treatment
CPAP & O2 successful in third of cases Deepen anaesthesia - Propofol – over 70% of cases. Muscle relaxant 9/21/2018 IARNA 2010
15
Laryngospasm - prevention
Adequate depth of anaesthesia ALWAYS HAVE IV BEFORE LARYNGOSCOPY Spray cords with local if working on airway Remove LMA early and ET either anaesthetised or awake. 9/21/2018 IARNA 2010
16
Laryngeal obstruction
Epiglottitis Papillomatosis Haemangioma Laryngeal web Vocal cord palsy 9/21/2018 IARNA 2010
17
Papillomatosis HPV 6 & 11 Repeated microdebriement Cidofovir ??
Don’t intubate. Discard circuit after single use. 9/21/2018 IARNA 2010
18
Haemangiomas Laser Tracheostomy Steroids B Blockers Propranolol
Acetbutalol 9/21/2018 IARNA 2010
19
Vocal cord paralysis Idiopathic, neurological, iatrogenic, birth trauma. Stridor, feeding difficulties 70% resolve. 9/21/2018 IARNA 2010
20
Foreign Body 9/21/2018 IARNA 2010
21
FB – post removal 9/21/2018 IARNA 2010
22
Laryngeal Cleft 9/21/2018 IARNA 2010
23
Laryngeal Cleft – Grade 1
9/21/2018 IARNA 2010
24
9/21/2018 IARNA 2010
25
9/21/2018 IARNA 2010
26
Difficult airway Difficult intubation Cant ventilate
0.08% healthy & 0.42% all children Anaesthesiology 2007;107:A1637 0.095% < 16 yrs & 0.24% < 1 yr Paediatr Anaesth 2004. Cant ventilate <0.02% difficult but never impossible. Anaesthesiology 2007;107:A1637 Adults 0.15% difficult to ventilate Anaesthesiology :891 9/21/2018 IARNA 2010
27
Diff ventilation More common in less experienced hands Anatomical
Functional Laryngospasm Light anaesthesia Inflated stomach Bronchospasm. 9/21/2018 IARNA 2010
28
Difficult intubation/ventilation
Anticipate Have a plan A, plan B and C if necessary. Maintain oxygenation Tracheostomy DON’T PANIC!!! GET HELP 9/21/2018 IARNA 2010
29
ANTICIPATE Congenital Structural Inflammatory Neoplastic
Cranio-facial abn – Pierre-Robin etc. Laryngotracheal – web, stenosis, malacia Structural foreign body, stenosis, burns, oedema, vascular. Inflammatory Croup, epiglottitis, papillomatosis, abscess Neoplastic Cystic hygroma, tumours. 9/21/2018 IARNA 2010
30
Assess – History Snoring Apnoea Stridor Blue Hoarse
Inspiration (extrathoracic e.g laryngomalacia) Expiration (intrathoracic) Blue Hoarse Daytime somnolence? Previous anaesthetic? Preferred position sitting? 9/21/2018 IARNA 2010
31
Assess - physical Failure to thrive – sleep disordered breathing
Caucasian v African children - UAO Dyspnoea Chest retractions Drooling saliva Weak cry Dysmorphic facies 9/21/2018 IARNA 2010
32
Additional Lung function tests – spirometry FEV1 Radiology
AP & lateral of neck and thoracic inlet CT & MRI Awake Endoscopy Anatomy + dynamic views Sleep studies 9/21/2018 IARNA 2010
33
Anaesthesia Inhalational induction – technique of choice
IV – occ used but in small doses so spontaneous respiration is maintained Always secure IV access before attempting intubation. Neuromuscular blockers best avoided Time !!! 9/21/2018 IARNA 2010
34
Difficult intubation Is airway secure? i.e oxygenation & ventilation
Is position correct? Is roll present? Is it too big? Use cricoid pressure How long do I attempt it? – assistant role! How many attempts – avoid trauma Do I need to intubate? – wake up or tracheostomy? 9/21/2018 IARNA 2010
35
Laryngeal mask airway Definitive airway May be used to ventilate child
As conduit for fibreoptic intubation Temporary airway until surgical airway secured 9/21/2018 IARNA 2010
36
Alternative laryngoscopes
Mc Coy Macintosh Seward Paediatric video laryngoscope Storz & Glidescope May assist in intubation Some reports of benefit Early in their use 9/21/2018 IARNA 2010
37
Fibreoptic intubation
Child must be anaesthetised, oxygenated and stable to allow time for intubation. ET in nostril or special mask. Topical anaesthesia 4% lidocaine Oral, via nasal ET tube, or via LMA. Try to maintain skills. 9/21/2018 IARNA 2010
38
Fibreoptic intubation oral, nasal.
Load tube onto scope Nasoendoscopes 2.2 – 2.5 mm no suction should take any size tube. Bronchoscopes 2.8 – 4 mm. Can take size 3.5 ET tube. Have suction May use suction port to deliver local 9/21/2018 IARNA 2010
39
OLCHC Plan Inhalational induction & IV access Anaesthetic intubation
Intubate with MLB setup (Parsons) Rigid bronchoscope & bougie Maintain airway with mask or LMA Tracheostomy 9/21/2018 IARNA 2010
40
Tracheostomy – when ? Cant intubate
Can intubate but with much difficulty Extubation may cause problem 9/21/2018 IARNA 2010
41
Cant intubate, cant ventilate
Very rare Needs structured protocol to manage 9/21/2018 IARNA 2010
42
Cricothyroidotomy complications
Pneumothorax Surgical emphysema Vascular injury Haemorrhage Haematoma False passage Aspiration Pulmonary barotrauma Subglottic oedema Subglottic stenosis Oesophageal perforation Infection 9/21/2018 IARNA 2010
43
Cricothyroidotomy APLS/Books percutaneous needle or surgical cricothyroidotomy In practice – trachea may be only mm in diameter therefore cricothyroidotomy very difficult 9/21/2018 IARNA 2010
44
Principles for paediatric diff intubation
Maintain oxygenation & ventilation Multiple and prolonged attempts at intubation cause morbidity – therefore limit to 4. Blind techniques have a high failure rate and cause trauma. Awaken patient and postpone surgery? 9/21/2018 IARNA 2010
45
Principles for paediatric cant intubate cant ventilate scenario
Use 2 person technique to ventilate LMA – frequently rescues situation If above fail – proceed to surgical airway. 9/21/2018 IARNA 2010
Similar presentations
