1. Pediatric Pearls I Delon F.P. Brennen MD,MPH Pediatrics / Pediatric Emergency Medicine Morehouse School of Medicine

2. Objectives Pediatric Airway and Airway Management Discuss Airway/Respiratory Emergencies

3. The Pediatric Airway  Anatomy / Physiology  Positioning  Adjuncts  Intubation

4. Introduction Almost all pediatric “codes” are of respiratory origin Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

5. Pediatric Cardiopulmonary Arrests 10% 80%

6. Anatomy Children are very different than adults !!!

7. Pediatric Airway Anatomy Issues –Large head that tends to flex the short neck and obstruct the airway –Disproportionately large tongue –Larynx is more cephalad and anterior –Cricoid cartilage is the narrowest point of the airway until about age 8 –Shorter trachea leaves less margin for error in placement of the endotracheal tube

8. Anatomy : NoseNose Responsible for 50% of total airway resistance at all ages Infants are obligate nasal breathers: blockage of nose = respiratory distress

9. Anatomy : TongueTongue Large Loss of tone with sleep, sedation, CNS dysfunction Frequent cause of upper airway obstruction

10. Anatomy : LarynxLarynx High position / Cephalad Infant : C1 6 months: C3 Adult: C5-C6 Anterior position

11. Children are different

12. Anatomy : Larynx Narrowest point = cricoid cartilage in the child

13. Anatomy : EpiglottisEpiglottis Relatively large size in children Floppy – not much cartilage Omega (  ) -shaped

14. Physiology: Effect of Edema Poiseuille’s law If radius is halved, resistance increases 16-fold R = 8 n l  r4 r4 r4 r4

16. Airway positioning for children <2yrs

17. Airway Positioning “Sniffing Position” In the child older than 2 years

18. Airway adjuncts Nasal airway Oral airway

19. Nasopharyngeal Airway Contraindications Basilar skull fracture CSF leak Coagulopathy Length: Nostril to Tragus Indications: Conscious Patient Conscious Patient Upper Airway obstruction – prolapse of tongue and mandibular block of tissue into the posterior pharynx Upper Airway obstruction – prolapse of tongue and mandibular block of tissue into the posterior pharynx

20. Endotracheal tube as nasal airway A regular ETT can be cut and used as a nasal airway

21. Oral Airways Measure: Lips to angle of the mandible Never in a conscious patient !!!

22. Adjuncts: Oral Airway Wrong size: Too Long

23. Adjuncts: Oral Airway Wrong size: Too Short

24. Adjuncts: Oral Airway Correct size

25. Signs of Respiratory Distress ? TachypneaTachypnea TachycardiaTachycardia GruntingGrunting StridorStridor Head bobbingHead bobbing FlaringFlaring Inability to lie downInability to lie down AgitationAgitation Retractions Retractions Access muscles Access muscles Wheezing Wheezing Sweating Sweating Prolonged expiration Prolonged expiration Pulsus paradoxus Pulsus paradoxus Apnea Apnea Cyanosis Cyanosis

27. Impending Respiratory Failure Reduced air entry Severe work Central Cyanosis despite O 2 Irregular breathing / apnea Grunting Altered Consciousness Diaphoresis

28. Intubation: Indications Failure to oxygenate Failure to remove CO 2 Increased WOB Neuromuscular weakness CNS failure Cardiovascular failure

29. Intubation Larynx cephalad and anterior in children – Practitioner may need to be lower than patient and look up

30. Laryngoscope Blades Macintosh Miller

31. Intubation Technique Straight Laryngoscope Blade (Miller) – used to pick up the epiglottis Better in younger children with a floppy epiglottis

32. Intubation Technique Better in older children who have a stiff epiglottis Curved Laryngoscope Blade (Mac) – placed in the vallecula

33. Intubation Agekg ETT Length (lip) Newborn3.53.59 3 mos6.03.510 1 yr104.011 2 yrs124.512 Children > 2 years: Children > 2 years: ETT size: Age/4 + 4 ETT depth (lip): Age/2 + 12 Children > 2 years: Children > 2 years: ETT size: Age/4 + 4 ETT depth (lip): Age/2 + 12

34. Technique: Intubation How far does it go in ?

35. Deterioration after Intubation D isplaced tube O bstructed tube P neumothorax E quipment D isplaced tube O bstructed tube P neumothorax E quipment

36. Questions ? Oh, it ain’t over!

37. The Test 6 week old infant comes to the ED with signs of respiratory distress. Which of the following would be consistent with impending respiratory failure? –Bilateral basilar rales –Resp Rate = 45bpm –Audible Grunting –Wheezing at the axillae –Acrocyanosis

38. Question 2 14 month old comes to the ED with cyanosis, tachypnea, and altered mental status. Which of the following supports the decision to intubate the child’s trachea immediately? –ABG with pH 7.25 –Pulse ox of 87% on RA –PaCO 2 of 56mmHg –PaO 2 of 56mmHg –Clinical assessment of respiratory failure

39. Question 3 Unconscious 15yo brought to the ED because of massive facial trauma and bleeding. He was punched and kicked by 4 girls and is now in respiratory distress. Which is the best method of securing his airway? –Nasopharyngeal airway –Nasotracheal intubation –Oropharyngeal airway –Cricothyroidotomy –Bag-Valve Ventilation –Testicular Implant

40. Question 4 6 week old brought to the ED. Mother is concerned that her baby “ain’ ackin right”. Which of the following vital signs reflect respiratory distress, failure, and shock? –RR 60bpm, HR 160bpm, SBP 75mmHg –RR 50bpm, HR 150bpm, SBP 75mmHg –RR 80bpm, HR 180bpm, SBP 60mmHg –RR 45bpm, HR 130bpm, SBP 80mmHg –RR 30bpm, HR 100bpm, SBP 70mmHg

41. Question 5 Which of the following physical findings is seen only in lower airway disease? –Audible grunting –Inspiratory Stridor –Tachypnea –Rales –Cyanosis

42. Question 6 5 yo with Asthma arrives in A&E in acute distress. Patient has marked tachypnea, subcostal retractions, and diffuse wheezing. Which method of O 2 delivery will deliver the highest possible concentration of oxygen? –Nasal cannulae –Face tent –Nonrebreather mask –Venturi mask

43. Question 7 You have just intubated the trachea of a 6 month old. Which of these best demonstrates the correct placement of an endotracheal tube? –Bilateral breath sounds over the chest + abd –Condensation in the tube –Slight improvement in the O 2 saturation –Assessment of end-tidal CO 2 –Chest wall movement

44. Question 8 3 hours later while receiving mechanical ventilation, the child acutely decompensates. Which of the following would be the least helpful in the management of this child? –Suction the ET –ABG –CXR –Auscultate both lung fields –Evaluate the ventilator

45. Question 9 Infants are more susceptible than adults to respiratory emergencies because of which of the following? –Greater resistance in lower airways –Larger tongue, small mandible, soft epiglottis –More compliant, less stable chest wall –Higher metabolic requirements –All of the above

46. Question 10 3yo brought to the ED after parents noted coughing while playing. Now have dyspnea and stridor. Which of the following is indicated at this time? –Four hard back blows –Finger sweep of child’s mouth –Nasotracheal intubation –Abdominal thrusts –Nebulized racemic epinephrine

47. Question 11 Pulse oximetry can be accurately used to monitor patients with all of the following except: –Hypoxemia –Carbon monoxide poisoning –Sickle cell disease –Cystic fibrosis –Cyanotic heart disease

48. Question 12 Which of the following clinical conditions is NOT an indication for intubation? –Hypoventilation –Loss of protective airway reflexes –Severe bronchospasm –Metabolic alkalosis –Pulmonary toilet

49. Question 13 Is that enough?

50. Issues?