Pediatric Prehospital Pediatric Prehospital Airway ManagementAirway Management

By: Aaron MillsBy: Aaron Mills

11/26/0711/26/07

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

As few as 10% of emergency calls involve As few as 10% of emergency calls involve a peds patient, of which only 1% involve a peds patient, of which only 1% involve

a critically ill or injured child.a critically ill or injured child.

Reasons Why These Reasons Why These Airways Are DifficultAirways Are Difficult

Emotional ResponseEmotional Response Different AnatomyDifferent Anatomy Structures not fully developedStructures not fully developed Large tongueLarge tongue

Pediatric Pediatric Cardiopulmonary ArrestsCardiopulmonary Arrests

10%

10%

80%

Respiratory

Shock

Cardiac

AnatomyAnatomy

Children are much harder to intubate than adults

Anatomy: LarynxAnatomy: LarynxNarrowest point = cricoid cartilage

Airway DifferenceAirway Difference

Airway PositioningAirway Positioning

““Sniffing Position”Sniffing Position”

Towel is placed under Towel is placed under the headthe head

Airway positioning for children <2yrsAirway positioning for children <2yrs

AdjunctsAdjuncts

Nasal airwayNasal airway

Oral airwayOral airway

Nasopharyngeal AirwayNasopharyngeal Airway

Contraindications:Contraindications: Basilar skull Basilar skull

fracturefracture CSF leakCSF leak

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

Adjuncts: Oral AirwayAdjuncts: Oral AirwayThe importance of proper The importance of proper

sizesize

Signs of Respiratory Signs of Respiratory DistressDistress

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 ApneaApnea CyanosisCyanosis

IntubationIntubation

Intubation: IndicationsIntubation: Indications

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

Neuromuscular weaknessNeuromuscular weakness CNS failureCNS failure Cardiovascular failureCardiovascular failure

Laryngoscope BladesLaryngoscope Blades

Macintosh

Miller

Using The Miller BladeUsing The Miller Blade

Better in younger Better in younger children with a floppy children with a floppy epiglottisepiglottis

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

ET Tube sizesET Tube sizes

AgeAge kgkg ETTETT Length (lip) Length (lip) NewbornNewborn 3.5 3.5 3.53.5 99 3 mos3 mos 6.06.0 3.53.5 1010 1 yr1 yr 10 10 4.04.0 1111 2 yrs2 yrs 1212 4.54.5 1212

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

Predicting the Difficult Predicting the Difficult AirwayAirway

Difficulty ventilatingDifficulty ventilating Facial traumaFacial trauma ObesityObesity ObstructionsObstructions Stiff lungs (asthma)Stiff lungs (asthma)

Difficulty intubatingDifficulty intubating External factors External factors

(obesity)(obesity) Evaluate mouth Evaluate mouth

openingopening ObstructionObstruction

Smaller airwaysSmaller airways

Neck mobility Neck mobility (trauma)(trauma)

Easy or Hard?Easy or Hard?

Easy or Hard?Easy or Hard?

Easy or Hard?Easy or Hard?

Back-up PlanBack-up Plan

Can’t ventilate or basics not workingCan’t ventilate or basics not working Consider adjuncts (OPA/NPA/positioning)Consider adjuncts (OPA/NPA/positioning) Intubation?Intubation?

Can’t intubateCan’t intubate Rescue devicesRescue devices

Can’t rescueCan’t rescue Surgical procedureSurgical procedure

Okay to stick with basics if workingOkay to stick with basics if working

OverviewOverview

Anatomy / PhysiologyAnatomy / Physiology PositioningPositioning AdjunctsAdjuncts IntubationIntubation

QuestionsQuestions??

ReferencesReferences

Hazinski MF, et al (Ed). Hazinski MF, et al (Ed). PALS provider manualPALS provider manual. AHA, 2005. . AHA, 2005. Lee BS, et al. Pediatric airway management. Lee BS, et al. Pediatric airway management. Clin Ped Emerg MedClin Ped Emerg Med. 2001. . 2001.

2(2): 91-106.2(2): 91-106. Lubitz DS. A rapid method of estimating weight and resuscitation drug Lubitz DS. A rapid method of estimating weight and resuscitation drug

doses from length in the pediatric age group. doses from length in the pediatric age group. Ann Emerg MedAnn Emerg Med.. 1998. 1998. 17(6):576-581.17(6):576-581.

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