Basics of Pediatric Airway Management

Monday, May 23, 2011

Basics of Pediatric Airway Management

Corey E. Collins, D.O., F.A.A.P Director, Pediatric Anesthesiology Massachusetts Eye and Ear Infirmary Boston, MA

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Corey E Collins, D.O.Monday, May 23, 2011

Pediatric Airway Anatomy

Narrowest part of airway is Cricoid Cartilage (vs V.C.)

Epiglottis and Tongue are relatively large

Larynx is Higher and Anteriorly tilted

Obligate Nasal Breathers until 6 mo

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laryngeal view when introducing a tracheal tube orother instruments. When open the blade forms an85-degree angle with the handle. It is our experiencethat for trainees and other inexperienced intubatorsthis together with the ease of view encourages thegentle indirect lift of the epiglottis rather than thetemptation to use a levering and potentially moreforceful action as may be the case when using aconventional straight or curved blade. Figures 2, 3and 4.

The McCoy laryngoscope was developed in theearly 1990s to help with difficult intubation in adult

patients (28). Lately a pediatric version of the McCoylaryngoscope, based on the Seward straight blade,has become available. It has been designed to conferthe advantages of the straight blade in aligning thevarious axes in the infant airway whilst allowingthe epiglottis to be lifted with the blade tip in thevallecula. It is suggested that that this should allow aview comparable to that of a straight blade (25).

The two more commonly used intubation aids arethe gum-elastic bougie and the malleable stylet. Thebougie has been used for difficult intubation via theorotracheal and nasotracheal route (29,30). The useof such intubation aids is not free of complicationboth with respect to the equipment used and thepotential for trauma (31,32). Latto et al. found thatalthough the gum-elastic bougie is commonly used,

Figure 2Laryngoscopists view with Cardiff blade (above) and Macintosh(below) to show relative positions of the respective blades whenplaced in the valeculla and the epiglottis is elevated to expose theglottis. The arrow illustrates the direction of lift required to obtainthis view with the Cardiff blade.

Figure 3Miller 1 (above) and Cardiff Blade (below). Two views todemonstrate the difference in blade configuration.

Figure 4Macintosh (above) and Cardiff Blade (below). Two views todemonstrate the difference in blade configuration.

PEDIATRIC LARYNGOSCOPES AND INTUBATION AIDS 33

! 2009 The AuthorsJournal compilation ! 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19 (Suppl. 1), 30–37


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Respiratory Physiology

Vt = 6-8 ml/kg same as adults

Increased VO2: 6-8 mL/kg/min vs 4-6

Increased Minute Ventilation via RR

FRC :: adults but the higher MV/ FRC results in faster desaturation

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Respiratory Physiology 2

Increased Chest wall compliance = less recoil

Higher Closing Capacity = desat if FRC falls

Decreased TLC: flat diaphragm, horizontal ribs (<5y)

Airway resistance ˆ4th power. Actual diameters are larger :: adults but any decrease will have more effect

“Economy of Breathing”

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Respiratory Physiology

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Airway Management

Consider need for intervention and risks

Indications

Impaired CNS

Obstruction

Increased Work of Breathing

Hypoxia

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Face MasksAlways keep a variety of sizes available

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Oral AirwaysAlways keep a variety of sizes available Beware of Gag, Laryngospasm, vomiting

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Length: Nostril to Tragus SIze of Nasal aperature

Nose to tragus Length

Contraindications

Basilar Skull Fx

CSF Leak

Coagulopathy

Nasopharyngeal Airway

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Supraglottic Airways

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Endotracheal TubesSizes Type Laser-safe RAE

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Endotracheal Tubes: SizePasses easily through V.C. Into subglottis

Leak < 20 cm H2O

16 + age/ 4

Have 0.5 mm larger and smaller

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Endotracheal Tubes: Cuff?Reintubation 23% vs 1.2%

Cuff Pressure?

Mucosal Injury?

Aspiration?

Bottom line: safe, smaller, low pressure

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Endotracheal Tubes: DepthMid tracheal Position

Age/2 +12

3x ETT Size

Withdrawal from Mainstem Bronchus

Concerns: Extubation, Cervical motion, injury, response

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Adjuncts neededAnticipate problems Have back-up plans for airway issues

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LaryngoscopesVariety of Sizes Choice of blade: age, personal preference, Anatomy

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Predictors of Difficult Intubations in Children

Syndromes

Decreased Mobility of Cervical Spine/ TMJ

Small mouth, receding jaw/ large overbite

Trauma

History of Difficult Intubation

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Bag Mask Ventilation

Properly sized Mask

Gentle but firm pressure/ Seal ~15cmH2O

Careful Positive Pressure Breaths/ Time respirations to Spont ventilations

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Endotracheal IntubationBe Careful Be Efficient Sit if possible Watch Forces/ Vagal Response Use Good Technique

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To provide direct view of glottis

Align 3 visual axis

Use laryngoscope to make final visulaization possible

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laryngeal view when introducing a tracheal tube orother instruments. When open the blade forms an85-degree angle with the handle. It is our experiencethat for trainees and other inexperienced intubatorsthis together with the ease of view encourages thegentle indirect lift of the epiglottis rather than thetemptation to use a levering and potentially moreforceful action as may be the case when using aconventional straight or curved blade. Figures 2, 3and 4.

The McCoy laryngoscope was developed in theearly 1990s to help with difficult intubation in adult

patients (28). Lately a pediatric version of the McCoylaryngoscope, based on the Seward straight blade,has become available. It has been designed to conferthe advantages of the straight blade in aligning thevarious axes in the infant airway whilst allowingthe epiglottis to be lifted with the blade tip in thevallecula. It is suggested that that this should allow aview comparable to that of a straight blade (25).

The two more commonly used intubation aids arethe gum-elastic bougie and the malleable stylet. Thebougie has been used for difficult intubation via theorotracheal and nasotracheal route (29,30). The useof such intubation aids is not free of complicationboth with respect to the equipment used and thepotential for trauma (31,32). Latto et al. found thatalthough the gum-elastic bougie is commonly used,

Figure 2Laryngoscopists view with Cardiff blade (above) and Macintosh(below) to show relative positions of the respective blades whenplaced in the valeculla and the epiglottis is elevated to expose theglottis. The arrow illustrates the direction of lift required to obtainthis view with the Cardiff blade.

Figure 3Miller 1 (above) and Cardiff Blade (below). Two views todemonstrate the difference in blade configuration.

Figure 4Macintosh (above) and Cardiff Blade (below). Two views todemonstrate the difference in blade configuration.

PEDIATRIC LARYNGOSCOPES AND INTUBATION AIDS 33

! 2009 The AuthorsJournal compilation ! 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19 (Suppl. 1), 30–37

Gentle Forces Proper Alignment Small movements Binocular Vision Stabilize arms/ pt head

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The abnormal airway

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The abnormal airway: Apert’s

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The abnormal airway: Treacher Collins

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Basics of Pediatric Airway Management

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