Pediatric Airway Emergencies

Elliot Melendez, MDPediatric Emergency Medicine and Critical CareChildren’s Hospital, Boston

Disclosures

No financial disclosures

No conflict of interest

Outline

Discussion of stridor

Challenges of pediatric airway

Rapid assessment for difficult airway

Critical airway management strategies

Highest Acuity Patients

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac

Resp. Distress

Respiratory failure

Shock

Cardiopulmonary Failure

Cardiac Arrest

Highest Acuity Patients

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac

Resp. Distress

Respiratory failure

Shock

Cardiopulmonary Failure

Cardiac Arrest

Highest Acuity Patients

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac

Resp. Distress

Respiratory failure

Shock

Cardiopulmonary Failure

Cardiac Arrest

Survival Data

Highest Acuity Patients

Precipitating Conditions

Respiratory Circulatory Sudden Cardiac

Resp. Distress

Respiratory failure

Shock

Cardiopulmonary Failure

Cardiac Arrest

Survival rates for resuscitation from: Resp arrest: 43 – 82% Cardiac arrest 4 – 14

%

Early recognition and treatment of respiratory compromise can improve outcome.

Case

6 month boy p/w fever and cough x 5 days

Cough is described as barky, and non-productive

Normal behavior, not irritable, decreased po’s

Case

VS: T 40.3, HR 150, RR 44, SaO2 95% on RA

Chest: coarse breath sounds, but no wheezing. Inspiratory stridor at rest without increased work of breathing

Remainder of exam unremarkable

Case

Decadron IM and racemic epinephrine neb were given with minimal improvement.

While in ED, biphasic stridor at rest with severe retractions, becomes toxic appearing. Some mild improvement to repeat racemic

epinephrine nebs Admitted to floor for observation

Case

Croup 6 mo to 6 years URI sxs Stridor +/- fever

Could there be an alternative diagnosis?

Stridor is the hallmark symptom associated with upper airway

disease

Rapid AssessmentHow Bad is it?

If distress is severe Ie. stridor at rest, cyanosis, severe retractions,

toxic appearing quickly examine and intervene

If stridor is mild: Then obtain a more complete and accurate

history develop a plan based on the differential

diagnosis

Stridor

Croup Clinical diagnosis Routine radiographs of neck or chest not indicated Dexamethasone therapy of choice for airway

edema If no stridor at rest, can send home

Who do you need to work-up?

Croup

When stridor is atypical for croup: Fixed stridor or isolated exhalatory stridor. Poor/No response to inhaled racemic

epinephrine and/or steroids

Extremes of age Greater than age 6, less than 6 month

Toxic appearing Persistently high fever. No viral prodrome, sudden onset

Work-up Atypical Stridor

Not all atypical stridor needs a work-up Admit and observe Physical Exam maneuvers Lateral and AP Neck CXR ENT consult

Physical Exam Maneuvers

Lay the infant Laryngomalacia worse with laying flat

Pass nasal catheter to determine the patency

Place in sniffing position and/or jaw thrust If the stridor lessens, obstruction may be at the

level of the larynx or higher

Atypical Stridor

Heavy drooling High fever Refusing to move

neck

Retropharyngeal Abscess

Typical presents 6-36 months

Look at prevertebral space

Complications include: Mediastinitis,

pericarditis, airway obstruction

Tip: Retropharyngeal swelling For C1-2

should be < ½ width of vertebral body

For C3-7 should be < width of

vertebral body False positives and

negatives: False (+): Flexion,

crying, +/- expiration False (-):

Parapharyngeal collection

Radiographs in Atypical StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign

bodies Mediastinal masses Congenital

anomalies

Steepling Analogies: Wine Bottles

BurgundyBordeaux

Steepling Analogies: NYC Buildings

Chrysler BuildingEmpire State Building

Steepling Analogies: NYC Buildings

Chrysler Building

Empire State Building

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign

Epiglottitis Radio-opaque foreign

bodies Mediastinal masses Congenital

anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign

bodies Mediastinal masses Congenital

anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign

bodies Mediastinal masses Congenital

anomalies

Radiographs in StridorOther Findings

Steeple’s sign Thumb sign Radio-opaque foreign

bodies Mediastinal masses Congenital

anomalies

Radiographs in StridorOther Findings

• Steeple’s sign• Thumb sign• Radio-opaque

foreign bodies• Mediastinal

masses• Congenital

anomalies

Right Sided Aortic Arch Aberrant left

subclavian artery gives rise to ductus arterious and compresses trachea

Surgery involves clipping of ligamentous arterious

Case

Worsened distress in AM Taken to the OR and DL performed.

Pus seen in trachea, intubated Culture grew Staph Aureus

Started on Unasyn (pre-MRSA) and improved

Bacterial Tracheitis

Pathology H. influenzae B was most common prior to

1992 or in unimmunized immigrants Staph Aureus most common, usually

superinfection. Other: GAS, pneumococcus, mycoplasma

AP neck x-ray: may show “thumb print” sign subtle

Patient Has Resp Compromise

You decide airway needs to be secured…..

Preparation? Equipment - SOAP ME Personnel

Prepare Equipment

S: Suction Catheters (6 - 16 french) and Yankauer tips (two sizes)

O: Oxygen and how to deliver Nasal cannula, oxygen flow, masks and appropriate bag

A: Airway Appropriate ETT, oral/nasal airway, stylets, laryngoscopes

P: Pharmacology RSI meds

ME: Monitoring equipment EtCO2 detector, stethescope, monitors

Artificial Airway Oral

Tip of mouth to corner of mandible

Artificial Airway

Nasal Nostril to tragus

Appropriate Size is Key

Correct size Incorrect size

(Atlas of Airway Management, 2007)

Endotracheal Tubes

Age Size (Inner Diameter, mm)

Premature 2.5

Term to 3 mo 3.0

3 to 7 mo 3.5

7 to 15 mo 4.0

15 to 24 mo 4.5

2 to 15 yr  

Internal diameter = [16 + age (yr)]/4 (round to the nearest 0.5 mm)(maximum 8.0)

Depth = ETT x 3 (lip)

Cuffed vs. Uncuffed?Prospective observational studies

No difference in the incidence of post-extubation stridor between 95 children intubated with uncuffed and 93 with cuffed ET tubes Deakers, TW, Reynolds, G, Stretton, M, et al. Cuffed

endotracheal tubes in pediatric intensive care. J Pediatr 1994;125:57.

No difference in use racemic epi for post-extubation subglottic edema between 387 children intubated with uncuffed and 210 with cuffed ET tubes Newth, CJ, Rachman, B, Patel, N, Hammer, J. The use of cuffed

versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004; 144:333.

Cuffed vs. Uncuffed?Khine HH, et al - Anesthesiology 1997

Full-term newborns through 8 yr (n = 488) Cuffed tube sized by a new formula = (age/4) + 3 Uncuffed tube modified Cole's formula = (age/4)

+ 4

Conclusion Formula for cuffed tube selection is appropriate Advantages of cuffed endotracheal tubes Avoidance of repeated laryngoscopy Cuffed tubes may be used routinely during controlled

ventilation in full-term newborns & children for anesthesia

Cuffed vs. Uncuffed?

Cuffed ET tubes may be placed by experienced intubators Except neonatal Size should be 0.5 – 1 mm smaller

Cuffed ET tube preferred for those with: Severe lung disease High ventilator pressures Bronchospasm or chronic lung disease Preferred by critical care physicians

Equipment: Blade and Tube Size

Age Blade/SizeInfant Miller 1

2 years old Miller 2

12 years old Miller/Mac 3

“Switch to a 2 at 2”

Prepare Personnel

Respiratory therapy, nurses, pharmacy

Assignment of roles Watch monitor Administer meds Sellick maneuver, Pull lip Pass ETT, aAttaching EtCO2

What are the particular issues in pediatrics which can effect airway management?

Pediatric Airway Issues

Airway management has it challenges…. Anatomic Physiologic Relatively less experience One size does not fit all

Anatomy

Occiput Relatively larger occiput causes passive flexion of c-

spine. Interferes with attempts to align the oral,

pharyngeal, and tracheal axes for visualization

Anatomy

Alignment Oral axis Pharyngeal axis Laryngeal axis

Anatomy

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., Copyright © 2006 Mosby, Inc.

    

Anatomy

Position of larynx In infants and children is

more anterior and superior than adults

More acute angle between the epiglottis and the glottic opening

Anatomy

Tongue Large compared to the

size of the oral cavity

Epiglottis Relatively large and

floppy in infants Epiglottis covers more

of the glottic aperture

Physiologic: Edema Effects

Poiseuille’s lawPoiseuille’s law

Physiologic ConsiderationsMore rapid cardiopulmonary decline

Increased risk of upper airway obstruction Prone to bradycardia

Laryngeal stimulation and hypoxia Higher oxygen consumption Lower functional residual capacity

Less oxygen reserve

Physiologic differences:Clinical evidence

(Patel et al., Can J Anaesth, 1994)

Relatively Less Experience

Adult Emergency Department Levitan, Acad Emerg Med, 2001 50,000 patients per year 500 airways/year

Pediatric Emergency Department Children’s Hospital, Boston data 50,000 patients per year 50 airways/year

Evaluating for the Difficult Airway

Case

11 mo brought to ED after dad was feeding child with edamame

Case

Mother heard coughing and gagging on child monitor

EMS called

Evaluation and Management

Evaluation Sudden onset Inspiratory stridor at

rest No fever Clear lungs High suspicion for

airway F.B.

Management LEAVE HIM ALONE!

No IV placement Remained in mother’s

lap ENT called stat

Recognition of Difficult Airway

Suspected/Known Craniofacial anomolies Croup/Epiglottis Vascular malformations Foreign body Mediastinal mass Cervical/Thoracic

abnormalities Facial/Oral Trauma

Recognition of Difficult Airway

Predictors - LEMON Look

Short neck, large tongue, micrognathia Evaluate 3-3-2

3 finger breadths of mouth opening 3 finger breadths submental to hyoid 2 finger breadths hyoid to thyroid

Mallampati Obstruction Neck mobility

Predict 100% success in AdultsNot validated in pediatrics

Predictors - LEMON Look

Short neck, large tongue, micrognathia

Evaluate 3-3-2 3 finger breadths of mouth opening 2 finger breadths submental to

hyoid (potential displacement area) 2 finger breadths hyoid to thyroid

Mallampati Obstruction Neck mobility

Historical Factors

Small jaws Congenital myopathies Pierre-Robin sequence, Crouzon

Large tongues Beckwith-Weiderman syndrome Infiltrative d/o’s – mucopolysaccharidosis Trisomy 21

Risk of malignant hyperthermia Duchene’s MD 25% Noonan’s syndrome >50%

Historical Factors

Small jaws Congenital myopathies Pierre-Robin sequence, Crouzon

Large tongues Beckwith-Weiderman syndrome Infiltrative d/o’s –

mucopolysaccharidosis Trisomy 21

Risk of malignant hyperthermia Duchene’s MD 25% Noonan’s syndrome >50%

Historical Factors

Small jaws Congenital myopathies Pierre-Robin sequence, Crouzon

Large tongues Beckwith-Weiderman syndrome Infiltrative d/o’s – mucopolysaccharidosis Trisomy 21

Risk of malignant hyperthermia Duchene’s MD 25% Noonan’s syndrome >50%

Known/Suspect Difficult AirwayManagement

Easy! Call for help

The difficult pediatric airway is best NOT managed by heroic or uncommonly used techniques

Carefully assess and plan Children with chronic/congenital issues has typically

been intubated in past check anesthesia records if time permits

Anticipate difficulties and prepare suitable back-up plan Call ahead, or know how to reach quickly, the

anesthesiologists and surgeon on-call

Case Scenario

Called to transport full term newborn with respiratory distress

Intubated at OSH with 3.0 uncuffed ETT

On team arrival, poor chest movement on high vent settings and audible air leak Decision to change ETT to 3.5 uncuffed

Clinical Decision Making

Options: Sedate, muscle relax Increase vent settings Direct laryngoscopy for tube position

Reintubate with larger tube, and/or cuffed tube

Goals of Larynoscopy What we want to see is this

Goals of Laryngoscopy The problem is…

…but we are here.

Cords are here…

Goals of Laryngoscopy

The problem is…

The aim is… To “see around the

corner”

• The goal of DL…• To get rid of the corner• To create straight line of

sight

Goal: Visualizing the CordsAligning the 3 Axes

Oral axis

Pharyngeal axis

Tracheal axis

Oral

Pharyngeal

Tracheal

Goal: Visualizing the CordsAligning the 3 Axes

Oral axis

Pharyngeal axis

Tracheal axis

Case Course

Under DL, visualized ETT through vocal cords, and removed.

3.5 uncuffed ETT passed easily through vocal cords

Bag-ETT performed with no chest rise, and immediate desaturation Recurs x4

In between, easy bag-mask with chest rise

Unrecognized Difficult AirwayManagement

Are you able to mask ventilate and oxygenate?

Difficult Intubation

Interventions Upgrade intubator Bag mask until advanced airway

interventions can be instituted Alternative modes

Difficult Airway

Difficult Mask Ventilation: inability to maintain SpO2 > 90% using 100%

oxygen and BMV

High risk Not only loss of airway, but risk of loss of vital

signs

Difficult Mask

Difficult Mask after failed intubation Move quickly to

alternative Immediate best

intubator Immediate to

alternative modes Fiberoptic, surgical

airways time consumption Rarely done Technically difficult in

peds

Alternative:Laryngeal Mask Airway

1981 - Dr. Archie Brain Royal London Hospital

Initially developed as a rescue tool

Laryngeal Mask Airway

LMA Size Patient Size

1 Neonate / Infants < 5 kg

1 ½ Infants 5-10 kg

2 Infants / Children 10-20 kg

2 ½ Children 20-30 kg

3 Children/Small adults 30-50 kg

4 Adults 50-70 kg

5 Large adult >70 kg

LMA: Insertion

Figure 42-10 Insertion of the laryngeal mask airway (LMA). A, The tip of the cuff is pressed upward against the hard palate by the index finger while the middle finger opens the mouth. B, The LMA is pressed backward in a smooth movement. Notice that the nondominant hand is used to extend the head. C, The LMA is advanced until definite resistance is felt. D, Before the index finger is removed, the nondominant hand presses down on the LMA to prevent dislodgment during removal of the index finger. The cuff is subsequently inflated, and outward movement of the tube is often observed during this inflation. (Courtesy of LMA North America, Inc., San Diego, CA.)

Mgmt of the Critical Airway

Can’t ventilate Can’t intubate

LMA contraindication (massive orofacial trauma) or not working

Cricothyrotomy < 5 years old

Needle cricothyrotomy and bag ventilation 5 to 10 years old

Needle cricothyrotomy and bag ventilation If oxygen saturation is inadequate: transtracheal

jet ventilation regulated to low PSI > 10 years

Operator preference Needle cricothyrotomy with TTJV or Surgical

cricothyrotomy

Percutaneous Transtracheal Ventilation

Beneficial for children who cannot be “ventilated” by other route

Experience level with this procedure is minimal

Percutaneous Transtracheal Ventilation

3-5cc syringe: 1-2cc saline OR 12- or 14-gauge IV

Summary

Pediatric airway emergencies are common

Stridor is the hallmark of an upper airway obstruction, thus emergency

Potential for difficult airway is high in pediatrics Identify resources, anticipate problems Familarize yourself with alternative techniques

Thank You!!!

Questions??