DrMoatazAbdelrahmanConsultantPaediatricAnaesthetistCentralManchesterUniversityHospitalsRoyalManchesterChildren’sHospital,UK

AIRWAYSURGERY

  EQUIPMENT  TECHNIQUES  TUBELESSAIRWAY  ANAESTHESIA  PROBLEMS  ADVANTAGES  DISADVANTAGES

Surgicalproceduresofthelarynxandtracheaininfantsandchildrenpresentspecialproblems  Narrowanatomicalfield  Aggravatedbypathologicalchanges

Sharedairway  Adequateoxygenation  Cooperation

REQUIREMENTSFORPAEDIATRICAIRWAYSURGERY

  Specialequipment

  Soundknowledgeoftheairway‐  Anatomy‐Physiology‐Pathology

  Tertiaryreferralcentre(wheneverpossible)

  Excellentcommunicationbetweenanaestheticandsurgicalteams

ACCESSTOTHEUPPERAIRWAY

  Rigidbronchoscopes  Storzventilatingscope±Hopkin’srod  Venturiscope(microtubes,jetventilation)

  Fibreopticscope

  Hopkin’srodwithoutbronchoscope

Light source

Light source

Telescope Hopkin’s Rod

FGF Suction

Prism

2.7 mm

SuggestedETTandrigidbronchoscopesizes

Age Cricoiddiameter

Trachealtube Bronchoscopesize

SizeID ED Size ID ED

Premature 4.0 2.5‐3.0 3.5‐4.0 2.5 3.2 4.0

Term 4.5‐5.0 3.0‐3.5 4.0‐4.9 3.0 4.2 5.0

6months 5.0 3.5‐4.0 4.9‐5.4 3.0 4.2 5.0

1yr 5.5 4.0‐4.5 5.4‐6.2 3.5 4.9 5.7

2yr 6.0 4.5‐5.0 6.2‐6.9 3.5 4.9 5.7

3yr 7.0 5.0‐5.5 6.9‐7.4 4.0 5.9 6.7

5yr 8.0 5.5‐6.0 7.4‐7.9 5.0 7.0 7.8

10yr 9.0 6.5cuff

14yr 11.0 6.5cuff

METHODSFORAIRWAYANAESTHESIA

  Storz  Spontaneous/IPPV  Apnoeicoxygenation

  Jetventilation(supraglotticandsubglottic)  Sanders Pneumothorax  HFJV CO2accumulation  LFJV

  Tubelessfield

ANATOMICALDIFFERENCES

  Largetongue  Longnarrowepiglottisangledposteriorly  Obligatorynasalbreathers  Softhighanteriorlarynx,easilydisplaced  Narrowestpartatthecricoidring  Shortcricothyroidmembrane

  Difficultcricothyroidotomy

ETT

Epig

Arytenoid

Aryepiglottic

Interarytenoid

VC

AIRWAYPHYSIOLOGY

  Fixedtidalvolume  Minuteventilationdependsonrate

  Diaphragmaticbreathing  FewertypeImusclefibres

  Earlyfatigue

  FRClessthanclosingcapacity  Highermetabolicrequirement

HYPOXIA

Infantslessthan60weekspostconceptualageareathighriskofdevelopingapnoeaespeciallyif

ex‐premature

PROCEDURESONTHEAIRWAY

  DIAGNOSTIC

  THERAPEUTIC

DIAGNOSTICPROCEDURES

  Laryngomalacia(floppyorflipperlarynx)

  Laryngo‐tracheo‐bronchomalacia

  Vocalcorddysfunction(palsies)

  Narrowingandstenoticlesions  Glottic  Subglottic  Tracheal

DIAGNOSTICPROCEDURES

  Tracheo‐oesophagealfistula

  Cysts(vocalcords)

  Clefts(larynx)

  Webs

  Tumours(papilloma)

  Inflammatorylesions

THERAPEURICPROCEDURES

  Excisionoflesions

  Laser

  DividingWebs

  Removalofforeignbodies

  Stentsforstenoticlesions(trachea)

  Correctionofclefts(larynx)

ANAESTHESIA

  Pre‐anaestheticassessment

  Anaestheticroompreparation

  Monitoring

  Induction

  Maintenance

  Analgesia

  Post‐anaesthesiacare

PREANAESTHETICASSESSMENT

  Ageatbirth  Post‐conceptualage  Ventilatoryproblemsatbirth–IPPV  Chroniclungdiseaseandbroncho‐pulmonarydysplasia

  Airwaymanifestations

  Previousanaestheticcharts  Investigations  Clearcervicalspine(rigidbronchoscopes)  Premedication

Airwaymanifestations

  Upperairway  Obstruction  Partial(monophasicorbiphasicstridor)  Complete(intubated–ICU)

  Oxygensaturation:low  Lowerairway:coughandwheeze  Feeding:historyofsevereregurgitation

ANAESTHETICROOM  Experiencedassistant  Localanaesthetic

  Spray  Atomiser

  Airwayequipment

  Laryngoscopes  Straightblades  Curvedblades

Face masks LMAs Tubes, stylets, bouggies Laryngoscopes Suction Cricothyroidotomy - tracheotomy

MONITORING

  ECG  BP  SpO2

  ETCO2  GAS

TUBELESSFIELDWITHHOPKIN’SROD

  Unobstructedairway  Noendotrachealtube  Nasopharyngealairwayformaintenance  TelescopeorHopkin’srodonly

INDUCTION

  SecuringIVaccessispreferablebeforeinduction

  Inhalationinduction  SevofluraneinO2  HaluthaneinO2  Isoflurane?  Desflurane?

  Maintainspontaneousbreathing+CPAP  Deepinhalation

  Confirmdeepanaesthesia  Centeraleyeballs‐smallpupils‐regularbreathing

  Insertnasopharyngealairway  ETTofappropriatesizestoppingshortoftheairway

  Localanaesthesiatotheairway  Laryngoscopy

  Lignocaine3mg/kg  Spray  LAD

  Assessthepositionofthetube  Maintainspontaneousbreathingthroughthe

nasopharyngealairway

Finalpicture:spontaneouslybreathingchildwithanaesthetisedairwayandnotubeinthelarynx

TubelessAirway

Readyforprocedure

ETT

Nasopharynx

MAINTENANCE  Gas/O2

  Spontaneousbreathing+CPAP(hand)  Equipment

  Drugs  Adrenaline▪Topical ▪Nebulizer

  Dexamethasone  Propofol

Tubes, stylets, bouggies LMAs Laryngoscopes Ventilating bronchoscope Suction Cricothyroidotomy - tracheotomy

PROBLEMS

  Rememberyouareworkingonadegreeofobstructiontostartwith

  Toodeep apnoea,lossofairway,desaturation

  Lightcoughing,airwayobstruction,desaturation

  InadequateCO2monitoring

PROBLEMS

  Difficultyinmaintainingspontaneousbreathing

  Airwaybleeding‐  Obstruction ‐Bronchospasm‐Desaturation

(Topicaladrenalineandsuction)

  Airwayobstruction‐Bleeding ‐Oedema‐Dislodgementofmasses ‐Traumatotheairway(rare)

ANALGESIA

  Localanaesthesia  Paracetamol  Ibuprofen

POSTANAESTHESIA

AIRWAYOEDEMA

AIRWAYBLEEDING

POSTANAESTHESIA

  Recoveryposition  AdequatetimeinPACU  Anaestheticandsurgicalteamsavailable

POSTANAESTHESIA

  Desaturation  Stridor  Obstruction  Apnoea

  Adrenalinenebulizer  1:1000@0.5ml/kg  RepeatPRN

  Dexamethasone  0.6mg/kg

  O2  CEPAP  Reintubate

ADVANTAGES

  Tubelessunobstructedfield  Lessmanipulationoftheairway

‐Intubation‐Extubation

  Facilitationofusinglargerinstruments  Nomusclerelaxants  LittleCO2accumulation  Minimalriskofpneumothorax

DISADVANTAGES

  Nodefinitiveairway

  Difficultyinmonitoringbreathing  ETCO2

  SomeCO2accumulation

CONCLUSION

Tubelessairwayfieldofferssomeadvantagesforsurgicalproceduresinasafemannerwithlesscomplications

REFERENCES

  1.AlbertSN.TheAlbert‐Sandersadaptorforventilatinganaesthetizedpatientsformicro‐laryngealsurgery.BrJAnaesth1971;43:1098

  2.BaerG,PaloheimoM,RahnastoJ,etal.End‐tidaloxygenconcentrationandpulseoximetryformonitoringoxygenationduringintratrachealventilation.JClinMonit1995;11:37

  3.CowlCT,PrakashUB,KrugerBR.Theroleofanticholinergicsinbronchoscopy:arandomised,clinicaltrial.Chest2000;118:188

  4.McRaeK.Anesthesiaforairwaysurgery.AnesthesiolClinNorthAmerica2001;19:497–541,vi

  5.KainZN,O’ConnorEZ,BerdeCB.Managementoftracheobronchoscopyandesophagoscopyforforeignbodiesinchildren:Asurveystudy.JClinAnesth1994;6:28

  6.OssoffRH.Lasersafetyinotolaryngology—headandnecksurgery:anestheticandeducationalconsiderationsforlaryngealsurgery.Laryngoscope1989;99:1–26

  7.EnglishJ,NorrisA,BedforthN.ContinuingEducationinAnaesthesia,CriticalCare&PainVolume6Number12006