Post on 25-Feb-2016
description
Upper airway obstruction in pediatric patients from anesthesiologist vew
Prof. Mirjana Shosholcheva University clinic of surgery “St. Naum Ohridski”
Medical faculty-Skopje, Macedonia
Disclosures
No financial disclosures
No conflict of interest
Key pointsCauses of airway obstruction in children
Signs of airway obstruction
Airway obstruction with foreign body
Airway obstruction during emergence from anaesthesia
Management of laryngospasm
Securing the airway in a child with airway obstruction
Epidemiology and mortality
Upper airway obstruction accounts for up to 15% pediatric emergency*
The major causes are: Viral croup (80%)** Epiglotitis (5%) Foreign body
aspiration
Failure to manage the airway is the leading cause of preventable
pediatric deaths
* Loftis L. Emergent evaluation of acute upper airway obstruction in children. Reprint from Up to date www.uptodate.com** Manno M. Pediatric respiratory emergencies: Upper airway obstruction and infections. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice . 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 166
Infants and children decompensate more quickly compared to
adults
Infections
Thermal injury
Congenital anomalies Post-
extubation laryngospasm
Depressed conscious level
Trauma
Rapidlyprogressive
Airwayobstruction
Airway foreign body
Life-threatening emergency
*Morton NS. Large airway obstruction in children: causes, assessment and management. Update Anaesthesia 2004; 18 (article 13):1
Laryngospasm after tracheal extubation –major of UAO after surgery
Important causes of airway obstruction in children
Anaphylactoid reactions
Signs of airway obstruction in children
- marked respiratory distress- altered voice- dysphagia- the hand-to-the-throat choking sign- stridor, facial swelling- prominence of neck veins- absence of air entry into the chest- tachycardia
conscious patient unconscious or sedated patient
- inability to ventilate with a bag-valve mask - asphyxia progresses to cyanosis- bradycardia- hypotension- irreversible cardiovascular
collapse
Obstructive noise or stridor is specific for UAO
Specifics regarding signs of airway obstruction in children
Mild upper airway obstruction child recovering from
anaesthesia tonsillar hypertrophy and
obstructive sleep apnea
Signs of partial upper airway obstruction
include biphasic snoring and mild
desaturation
Severe, non-complete, progressive airway obstruction increased work of breathing respiratory failure Hypoxemia cardiac arrest
Children with severe croup, tracheitis,
epiglottitis, airway burns
Trauma, depending on its severity and location, may produce immediate or progressive obstruction
TachypneaParadoxical respiration “See-saw” pattern of breathing(dyssynchrony between rib cage and abdomen)Suprasternal, intercostal, and subcostal retraction along with
an increased use of accessory muscles of respirationauto CPAPPosition: Infants may assume an opisthotonic position; the
"tripod" or sniffing position is seen in the older child
Signs of increased work of breathing
Inspiratory stridor Expiratory stridor
Stridor
The magnitude or severity of stridor does not correlate with the severity of obstruction
airway compromise at the supraglotic or laryngeal level intrathoracic obstruction
Signs of ineffective breathing and respiratory failure:
CyanosisAltered consciousnessBradypnea, apneic spelssSilent chest in spite of vigorous effort
Compleet airway obstruction
Choking, absent breath sounds and aphonia This rapidly progresses to cyanosis, bardycardia and cardiac arrest
Post-extubation laryngospasm, angiooedema and
anaphylactoid reactions
Airway obstruction with foreign bodyForeign-body aspiration is a relatively frequent accident and
a leading cause of accidental death in children under 5 years of age
Diagnosis of foreign body aspiration should be suspected in children who do not respond to appropriate
intervention
Laryngeal impaction is life-threatening(large or sharperdged foreign bodies may lodge in the larynx)
Most foreign bodies pass the vocal cords and lodge in the lower airways (bronchi -80%)
Symptoms can mimic other diseases such as croup or asthma
• Children with a history of choking and subsequent symptoms must be referred to immediate bronchoscopy!
Airway obstruction with foreign body
• Oropharyngeal foreign bodies :mouth breathing
• Nasal foreign bodies unilateral rhinorrhea and stinking breath
What about the child who has stridor and wheezing?
The causes of stridor and wheezing in older infants and children include foreign bodies in the airway and in the esophagus
and combination of infectious causes
Management of airway obstruction with foreign body
*Schmidt H., Manegold BC. Foreign body aspiration in children. Surg Endosc 2000; 14:644-8
*if the child can cough and verbalized it is placed in the position of comfort and oxygen is given
IV line placement and other interventions which may agitate the child in this case are avoided
X-ray evaluation for localization can be performed urgently in stable children
The presence of asphyxia indicates the need for immediate resuscitation and securing the airway
“Circulus viciosus”BLS maneuvers(Heimlich, Guidel )
direct laryngoscopy
Complications1. Mild oedema of the respiratory mucosa
2. Tracheobronchitis3. granulation tissue
Most patients can be discharged within 24 h
Magill forceps or suction
flexible bronchoscopy
short course of corticosteroids
Repeat bronchoscopy rigid bronchoscopy
Child is in respiratory distress!inhalational induction with 100% oxygen and sevoflurane
After loosing the consciousness. i.v. cannula
TIVA with propofol and fentanyl
cords are sprayed with local anaesthetic
gentle assistance with inhalational technique
rigid bronchoscope with a ventilating side arm is inserted, facilitated by laryngoscopyhigher FiO2
DexamethadoneThe foreign body is withdrawn by a forceps through the bronchoscope
Laryngeal edema might be worsening after multiple insertions of the rigid bronchoscope, and post-procedure reintubation might be required
Securing the airway in a child with airway obstruction – General considerations
Laryngoscopy and intubation
Sevoflurane might be choice, but its use has some controversy, because lower potency of sevoflurane may not permit intubation
Attempts to assist ventilation against complete obstruction are usually futile!
Alveolar ventilation in these children is severely compromised. Uptake of volatile agents is very slow and induction of anaesthesia may take more than 15 min
volatile anaesthetics
The Jackson-Rees modification of Ayer,s “T piece” circuit- CPAP
Any attempt at “asynchronous” assistance leads to complete obstruction, especially in large
foreign bodies
“Synchronized” assistance (analogous to triggered ventilation) is very helpful to maintain oxygenation
intubation is difficult or impossible
If the condition of the child deteriorates, cricothyrotomy and ventilation through
a T piece circuit can be considered
Jet ventilation is not appropriate as it may lead to barotrauma
flexible fiberoptic bronchoscopy
As the depth of anaesthesia increases, the child may be gradually lowered to the
supine position
The safest option is emergent tracheostomy under musk anaesthesia for most children who cannot be intubated in one or two attempts
Controversy associated with heliox therapy in UAO
Heliox has been used in several conditions: postextubation laryngeal edema, tracheal stenosis or extrinsic compression, status asthmaticus and angioedema
To be effective, the helium–oxygen ratio must be at least 70:30
Although the work of breathing and dyspnea improves to some degree with the use of heliox, the mechanical obstruction is still in placeThe use of heliox in patients with severe UAO should only be
used to provide temporary support pending definitive diagnosis and management
Algorithm for management of upper airway obstruction
Infective causes of airway obstruction
Usually affects children from 6 months to 4 years of age, with a peak incidence at 2 years of age
Endoscopic view of subglottic oedemain viral croup
Radiological presentation of subglottic oedema in viral croup (left) compared with
a normal trachea (right)
acute clinical syndrome of hoarse voice, barking cough and stridor
There is some controversy regarding treatment with epinephrine
Schematic (left) and endoscopic view (right) of epiglottitis.
Lateral neck radiographs of a normal child (left) and a child with epiglottitis with the typical thumb sign (right).
Epiglotitis
Conversely, epinephrine is not effective in the treatment of epiglottitis and may be deleterious.
Controversy! To look or not to look
Airway burns
Exposure in an enclosed spaceDecreased level of consciousness, confusion
Soot in mouth, nares
Swelling, ulceration of oral mucosa or tongue
Suspect for inhalation injury
Carbonaceous sputum
Dyspnoea
Hoarseness
Stridor, wheeze, crepitations
Increased work of breathingOxygen saturations <94% in air
Caboxyhaemoglobin >5% on co-oximetry
Heat produces an immediate injury to the airway mucosa edema
Effect of deep face burns on airway maintenance are:Airway obstruction by intraoral and laryngeal edema
Anatomic distortion by face and neck edema, which increases the difficulty of endotracheal intubation
Oral edema decreasing clearance of intraoral secretion
Impaired protection of the airway from aspiration
Maintaining an adequate airway!
Maintain airway patencyProtect against aspirationPulmonary toilet to decrease mucous plugging and infection risks
Need for positive-pressureWhen in doubt, it is safer to intubate!
TRAUMATIC LESIONS
Damage from endotracheal intubation andtracheotomy
Even the dictum that ‘cuffed endotracheal tubes should not be used inchildren under the age of 8 years’ can no longer be maintained
since the development of high-volume, low-pressure cuffs*
*Newth CJL, Rachman B, Patel N, Hammer J. The use of cuffed versusuncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004; in press
Endotracheal tube complications incorrect size, traumatic or multiple intubations up and down movements of the endotracheal tube inadequate analgesia and sedation, whereby the infants struggle while intubated
Cuff vs Uncuffed Endotracheal Tube
Controversial issue
Traditionally, uncuffed ETT recommended in children < 8 yrs old to avoid post-extubation stridor and subglottic stenosis
Arguments against cuffed ETT: smaller size increases airway resistance, increase work of breathing, poorly designed for pediatric patients, need to keep cuff pressure < 25 cm H2O
Arguments against uncuffed ETT: more tube changes for long-term intubation, leak of anesthetic agent into environment, require more fresh gas flow > 2L/min, higher risk for aspiration
-
Concluding Recommendations - For “short” cases when ETT size >4.0, choice of
cuff vs uncuffed probably does not matter
Cuffed ETT preferable in cases of: high risk of aspiration (ie. Bowel obstruction), low lung compliance (ie. ARDS, pneumoperitoneum,
CO2 insufflation of the thorax, CABG), precise control of ventilation and pCO2 (ie. increased
intracranial pressure, single ventricle physiology)
Golden, S. “Cuffed vs. Uncuffed Endotracheal tubes in children: A review” Society for Pediatric Anesthesia. Winter 2005 edition.
Laryngeal Mask Airway – WHEN?
Supraglottic airway device
Flexible bronchoscopy, radiotherapy, radiologic procedures, urologic, orthopedic, ENT and ophthalmologic cases are most common pediatric indications for LMA
Useful in difficult airway situations, and as a conduit of drug administration (ie. Surfactant)
Different types of LMAs: Classic LMA, Flexible LMA, ProSeal LMA, Intubating LMA
Disadvantages: Laryngospasm, aspiration
Airway obstruction during emergence from anaesthesia
Postoperative laryngospasm - life-threatening complication aspiration, airway obstruction
local irritation by blood or saliva light planes of anaesthesia Child undisturbed - in the lateral recovery position
Tracheal extubation
HypoventilationHypoxemiaHypercarbiaCardiac dysrhythmiasCardiac arrest
deep anesthesia
awake
Concern:light plane of anesthesia!
Emergence and extubation: A systemic approach
Can this patient be extubated while deeply anesthetized?
Yes No
- No rezidual NMB- Easy musk ventilation- Easily intubated- Not at increased risk forregurgitation/aspiration- Normothermic
- Difficult musk ventilation- Difficult intubation- Residual NMB present- Full stomach
Can this patient be extubated immediately following surgery and emergence from general anesthesia?
Can this patient be extubated immediately following surgery and emergence from general anesthesia?
Yes No - Awake- Following commands- Breathing spontaneuosly- Wheel oxigenated
- Not excessively hyperbaric- (PaCo2 50 mmHg
- Fully recovered from MR- Sustained head lift- Strong hand grip- Strong tongue protrusion
- Hypoxic (O2 saturation < 90 mmHg)
- Excessively hyperbaric(Pa CO2 >50mm Hg
- Hypothermic (< 34 C)- NMB present
Partial laryngospasm complete laryngospasm
inspiratory stridor
Increased airway problems
children with a history of a recent upper respiratory tract infection former premature infants
children with chronic, obstructive sleep apnea
absence of air movementTracheal tug and paradoxical (“see-saw”) movement of the abdomen
If necessary a dose of succinylcholine followed by tracheal re-intubation (in children older than 2 years!!!)
mild biphasic snoring-noisy breathing
Managament of laryngospasm
jaw thrust maneuver, neck extension and mouth opening
placing the child in the “safe” position
oxygen by face mask positive pressure with a bag and face mask may be required along with a naso-pharyngeal airway
Of particular concern have been the instances of life-threatening malignant hyperpyrexia and reports of rare, but often fatal, hyperkalaemic cardiac arrests in young boys with undiagnosed muscular dystrophy. As a result of these reports, in 1994, the US Food and Drug Administration (FDA) recommended that ‘the use of succinylcholine in children should be reserved for emergency intubation and instances where immediate securing of the airway is necessary, e.g. laryngospasm, difficult airway, full stomach, or for i.m. use when a suitable vein is inaccessible’. Since the publication of this recommendation, the use of succinylcholine in routine anaesthesia in children has been declined.
RISK OF CARDIAC ARREST FROM HYPERKALEMIC RHABDOMYOLYSIS
This syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes after the administration of the drug in healthy appearing children (usually, but not exclusively, males, and most frequently 8 years of age or younger).
There have also been reports in adolescents.
Recent concerns about the elective use of succinylcholine in pediatric patients have focused on the occasional reports of hyperkalemic cardiac arrest, particularly in children with undiagnosed Duchenne muscular dystrophy. The incidence of Duchenne muscular dystrophy is only 1 in 3000 to 8000 male children. The revised labeling continues to permit the use of succinylcholine for emergency control of the airway and treatment of laryngospasm.Succinylcholine is the only neuromuscular blocking agent currently available that has been demonstrated to be effective after intramuscular (IM) administration when emergency control of the airway is required and there is no IV access. In this circumstance, the dosage must be increased to 4 to 5 mg/kg IM. Atropine is administered simultaneously. Following IM succinylcholine, onset of neuromuscular blockade takes approximately 2 to 5 minutes; the response in patients who are hypotensive or hypovolemic is unpredictable.
Airway irritation/obstruction
Blood/secretions
Light anaesthesia
Regurgitation
In the Proposed Approach to the management of laryngospasm first of all is to think of:
The main aim is to rapidly oxygenate child!
100% oxygen (warm, humidified, oxygen enriched air mixture in neonates)
Visualize and clear pharynx/airway
Jaw thrust with bilateral digital pressure behind temporomandibular joint, oral/nasal airway
Deepen anaesthesia with propofol (20% induction dose)Succinylcholine 0.5 mg/kg to relieve laryngospasm (1.0-1.5 mg/kg i.v. or 4.0 mg/kg i.m. for intubation
Be aware of use in children < 2 years old!!!Intubate and ventilate
Associated risk factors
Airway obstruction in the postoperative period
post-intubation croup
Laryngeal edema - in neonates and infants = inspiratory stridor within 6 h of extubation (Subglottic edema of 1 mm in neonates can reduce the laryngeal lumen by 35%)
- Supraglottic oedema- Retroarytenoidal oedema- Subglottic oedema
tight fitting tubetrauma at intubationduration of intubation >1 hcoughing on the tubechange of head and neck position during surgery
Management of laryngeal edema
warm, humidified, oxygen enriched air mixture
nebulized epinephrine 1:1000 (0.5 ml kg−1 up to 5 ml)
dexamethasone 0.25 mg kg−1 followed by 0.1 mg kg−1 six hourly for 24 h
reintubation with a smaller tube in severe cases
● Upper airway obstruction (UAO) is a life-threatening emergency that requires prompt diagnosis and treatment
● Severe UAO can be surprisingly asymptomatic at rest if it develops gradually. Sudden clinical deterioration is unpredictable
● Patients with possible UAO must never be sedated until the airway is secured. Minimal sedation may precipitate acute respiratory failure
● Achievement of airway patency in total airway obstruction and reestablishment of ventillatory airflow is the first and foremost goal of the anaesthesiologists
Conclusion
● Critical care physicians must be aware that pharmacologic interventions (epinephrine, steroids, and heliox) provide temporary support but cannot significantly improve mechanical UAO
● Bronchoscopy constitutes the most accurate diagnostic tool and frequently provides the best way to correct UAO
● Cricothyroidotomy is the surgical intervention of choice to reestablish airflow when medical interventions have failed
Conclusion
If the anaesthesiologist is competent in the full range of airway access procedures and
when appropriately management is performed, the possibility of incidence and
consequences of acute airway obstruction in children will be very low
Conclusion
Thank you