Pediatric Airway Pediatric Airway ManagementManagement

Margaret Winkler, MDMargaret Winkler, MD

Pediatric Critical CarePediatric Critical Care

University of Alabama at University of Alabama at BirminghamBirmingham

The Pediatric AirwayThe Pediatric Airway

IntroductionIntroduction Anatomy / PhysiologyAnatomy / Physiology PositioningPositioning AdjunctsAdjuncts IntubationIntubation

IntroductionIntroduction

Almost all pediatric “codes” are of Almost all pediatric “codes” are of respiratory originrespiratory origin

Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

Pediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary ArrestsPediatric Cardiopulmonary Arrests

1° Respiratory

Shock

1° Cardiac

1° Respiratory

Shock

1° Cardiac

10% 10%

80%80%

Age distribution of arrestsAge distribution of arrests

0

5

10

15

20

25

30

35

40

<7 mos 151413121110987654321

7-12

mos

Age (years)

# A

rres

ts

Schindler M, et al. Outcome of out-of-hospital cardiac or Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479.respiratory arrest in children. N Engl J Med 1996;335:1473-1479.

Arrive in ER in Arrive in ER in cardiac arrestcardiac arrest

(N = 80)(N = 80)

Admit PICUAdmit PICU(N=43) 54 %(N=43) 54 %

Died in ERDied in ER(N=37) 46%(N=37) 46%

Mod DeficitMod Deficit(N=3)(N=3)

PVS at PVS at 12 mos12 mos(N=2)(N=2)

Dead at Dead at 12 mos12 mos(N=1)(N=1)

Died in ICUDied in ICU(N=37) 46%(N=37) 46%

AnatomyAnatomy

Children are very different than adults !!!Children are very different than adults !!!

Anatomy : NoseAnatomy : Nose

• Nose is responsible for 50% of total airway Nose is responsible for 50% of total airway resistance at all agesresistance at all ages

• Infant: blockage of nose = respiratory Infant: blockage of nose = respiratory distressdistress

Anatomy : TongueAnatomy : Tongue

• LargeLarge• Loss of tone with sleep, sedation, CNS Loss of tone with sleep, sedation, CNS

dysfunctiondysfunction• Frequent cause of upper airway obstructionFrequent cause of upper airway obstruction

Anatomy : LarynxAnatomy : Larynx

• High positionHigh position• Infant : C 1Infant : C 1

• 6 months: C 36 months: C 3

• Adult: C 5-6Adult: C 5-6• Anterior positionAnterior position

Children Children areare different different

Anatomy : LarynxAnatomy : Larynx

Narrowest point = cricoid cartilage in the childNarrowest point = cricoid cartilage in the child

Anatomy : EpiglottisAnatomy : Epiglottis

• Relatively large size in childrenRelatively large size in children• Omega shapedOmega shaped• Floppy – not much cartilageFloppy – not much cartilage

Physiology: ResistancePhysiology: Resistance

Peripheral airways contribute to total airways Peripheral airways contribute to total airways resistance:resistance:

AdultAdult 20%20%

ChildChild 50%50%

Physiology: Effect of EdemaPhysiology: Effect of EdemaPoiseuille’s lawPoiseuille’s law

If radius is If radius is halvedhalved, resistance increases , resistance increases 16fold16fold

R =R = 8 n l8 n l rr44

Airway positioning for Airway positioning for children <2yrschildren <2yrs

Airway PositioningAirway Positioning

““Sniffing Position”Sniffing Position”In the child older than 2 yearsIn the child older than 2 years

Towel is placed under the headTowel is placed under the head

Airway adjunctsAirway adjuncts

• Nasal airwayNasal airway• Oral airwayOral airway

Nasopharyngeal AirwayNasopharyngeal Airway

Contraindications:Contraindications: Basilar skull fractureBasilar skull fracture CSF leakCSF leak CoagulopathyCoagulopathy

Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus

Endotracheal tube as nasal airwayEndotracheal tube as nasal airwayEndotracheal tube as nasal airwayEndotracheal tube as nasal airway

A regular ETT A regular ETT can be cut and can be cut and used as a nasal used as a nasal airway airway

Adjuncts: Oral AirwayAdjuncts: Oral Airway

Wrong size: Too LongWrong size: Too Long

Adjuncts: Oral AirwayAdjuncts: Oral Airway

Wrong size: Too ShortWrong size: Too Short

Adjuncts: Oral AirwayAdjuncts: Oral Airway

Correct sizeCorrect size

Oral AirwaysOral Airways

Signs of Respiratory DistressSigns of Respiratory Distress

• TachypneaTachypnea• TachycardiaTachycardia• Grunting Grunting • StridorStridor• Head bobbingHead bobbing• FlaringFlaring• Inability to lie downInability to lie down• AgitationAgitation

• RetractionsRetractions• Access musclesAccess muscles• WheezingWheezing• SweatingSweating• Prolonged expirationProlonged expiration• Pulsus paradoxusPulsus paradoxus• ApneaApnea• CyanosisCyanosis

Impending Respiratory FailureImpending Respiratory Failure

• Reduced air entryReduced air entry• Severe workSevere work

• Cyanosis despite OCyanosis despite O22

• Irregular breathing / apneaIrregular breathing / apnea• Altered ConsciousnessAltered Consciousness• DiaphoresisDiaphoresis

Respiratory FailureRespiratory Failure

• Hypoxic respiratory failureHypoxic respiratory failure• Hypercarbic respiratory failureHypercarbic respiratory failure

HypoxemiaHypoxemia

• Inadequate inspiratory Inadequate inspiratory partial pressure of oxygenpartial pressure of oxygen

• Global alveolar Global alveolar hypoventilationhypoventilation

• Right to left shuntRight to left shunt• V/Q mismatchV/Q mismatch• Incomplete diffusion Incomplete diffusion

equilibriumequilibrium

•Low barometric pressure or Low barometric pressure or FIO2FIO2•High PaCO2High PaCO2

•Little change with extra oxygenLittle change with extra oxygen•Good response to O2Good response to O2•Good response to O2Good response to O2

MechanismMechanism Distinguishing AttributeDistinguishing Attribute

Incomplete diffusion equilibriumIncomplete diffusion equilibrium

• Thickened alveolocapillary membrane (true Thickened alveolocapillary membrane (true diffusion block)diffusion block)

• Abnormally low oxygenation of mixed Abnormally low oxygenation of mixed venous blood venous blood

• Lung damage or destruction, resulting in Lung damage or destruction, resulting in reduced alveolar capillary volumereduced alveolar capillary volume

• Increased CO with reduced alveolar Increased CO with reduced alveolar capillary transit timecapillary transit time

Intubation: IndicationsIntubation: Indications

• Failure to oxygenateFailure to oxygenate• Failure to remove COFailure to remove CO22

• Increased WOBIncreased WOB• Neuromuscular weaknessNeuromuscular weakness• CNS failureCNS failure• Cardiovascular failureCardiovascular failure

IntubationIntubation

• Larynx cephalad and anterior in Larynx cephalad and anterior in childrenchildren

– Practitioner may need to be Practitioner may need to be lowerlower than patient and than patient and look uplook up

Cephalad and anteriorCephalad and anterior

Laryngoscope BladesLaryngoscope Blades

Macintosh

Miller

Intubation TechniqueIntubation Technique

Straight Laryngoscope Blade – used to pick up Straight Laryngoscope Blade – used to pick up the epiglottisthe epiglottis

Better in younger Better in younger children with a children with a floppy epiglottisfloppy epiglottis

Intubation TechniqueIntubation Technique

Curved Laryngoscope Blade – placed in the valleculaCurved Laryngoscope Blade – placed in the vallecula

Better in older Better in older children who children who have a stiff have a stiff epiglottisepiglottis

IntubationIntubation

AgeAge kgkg ETTETT Length (lip) Length (lip)

NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Technique: IntubationTechnique: Intubation

How far does How far does it go in ?it go in ?

Deterioration after IntubationDeterioration after IntubationDeterioration after IntubationDeterioration after Intubation

• DDisplaced tubeisplaced tube

• OObstructed tubebstructed tube

• PPneumothoraxneumothorax

• EEquipmentquipment

• DDisplaced tubeisplaced tube

• OObstructed tubebstructed tube

• PPneumothoraxneumothorax

• EEquipmentquipment