1 Pediatric Airway Managementدکتر مهرزاد آرتنگ رییس اداره اورژانس پیش بیمارستانی دانشگاه 1392/4/1

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3 Pediatric Cardiopulmonary ArrestsIn most infants and small children respiratory arrest precedes cardiac arrest.

4 Characteristics of Newborn Respiratory SystemInfant lung is a unique structure not a mini- adult lung Airways, distal lung tissue and pulmonary capillary bed continue to grow and develop after birth Alveoli development complete and adult anatomy by 8-10 years of age Ossification of ribs and sternum complete by 25 years of age

5 Nose Tongue Obligatory nasal breathing Poor tolerance to obstructionRelatively Large Neck extension may not relieve obstruction Tongue

6 Head Epiglottis Relatively largeAnterior flexion may cause airway obstruction Relatively large and U- shaped More susceptible to trauma Forms more acute angle with vocal cords Epiglottis

7 Cricoid Narrowest portion of airway↑ resistance with airway edema or infection Acts as “cuff” during tracheal intubation

8 Effect Of Edema If radius is halved, resistance increases 16 x

9 Trachea Small diameter (6mm), high compliance↑ resistance with airway edema or infection Collapses easily with neck hyperflexion or hyperextension ↑ pulmonary vascular resistance (PVR) Very sensitive to constriction by hypoxia, acidosis and hypercarbia

10 Regulation of BreathingWOB Weak resp muscles Response to ↓ O2/ ↑ CO2 minimal Tolerates hypoxia poorly Regulation of Breathing

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12 Assessment 30 second rapid cardiopulmonary assessment is structured around ABC’s. Airway Breathing Circulation

13 Airway Airway must be clear and patent for successful ventilation.Position Clear of foreign body Free from injury Intubate if needed 

14 “Patients do not die fromlack of intubation they die from lack of oxygenation”

15 Cricoid Pressure (Sellick's Maneuver)Cricoid pressure is indicated in the intubation of those who are deeply unconscious and in those who have been paralyzed for intubation.

16 Breathing Breathing is assessed to determine the child’s ability to oxygenate. Assessment: Respiratory rate Respiratory effort Breath sounds Skin color

17 Impending Respiratory FailureRespiratory rate less than 10 or greater than 60 is an ominous sign of impending respiratory failure. Prearrest. s

18 Airway assessment Best to 1st look from afar. Infants and small children don’t like strangers hard to assess baseline after they are upset. Is the chest moving? Can you hear breath sounds? Are there any abnormal airway sounds ? (e.g.. Stridor, snoring) Is there increased respiratory effort with retractions or respiratory effort with no airway or breath sounds?

19 Breathing RR Effort Airway and lung sounds SpO2

20 RR Best to evaluate prior to hands-on assessmentExcitement, anxiety, exercise, pain, fever, agitation can all ↑ RR ↓ RR with acutely ill child or with ↓ LOC = ++ cause for concern > 60 in any age is cause for concern Normals As per PALS Age BPM Infant (<1 yr) 30-60 Toddler (1-3) 24-40 Preschool (4-5) 22-34 School age (6-12) 18-30 Adolescent(13-18) 12-16

21 Signs of Respiratory DistressTachypnea Tachycardia Grunting Stridor Head bobbing Flaring Agitation Retractions Access muscles Wheezing Sweating Prolonged expiration Apnea Cyanosis

23 Lung Sounds Normal Wheezes Rales (Crackles) Stridor RhonchiPleural Rub Listen on every patient End of Expiration End of Inspiration During both phases Expiration

24 Airway Management Simple things to improve airway patencySuction nose and oropharynx child/ allow child to assume position of comfort head-tilt-chin lift/ jaw thrust Use airway adjuncts - NPA/ OPA

25 Oral & Naso pharyngeal SuctioningClean technique Negative pressure of 80 to 120 mmHg. Test suction level on regulator prior to suctioning Nasal and oral suction can be performed with same catheter May result in hypoxia?, ↓ HR (vagal), bronchospasm, larygospasm, atelectasis Neonates 5-6 Fr Infants 6-8 Fr Older kids 10 Fr

26 هیپوکسی و ساکشن برای جلوگیری از این مشکل ، ساکشن کردن را به 15ثانیه در بالغین و 5 ثانیه در اطفال محدود کنید .

27 Oral Pharyngeal Airways (OPA)Only for use in UNCONSCIOUS pt with no intact cough/gag reflex Never tape in place

28 Choosing correct OPA

29 SIZE COLOUR 000 Violet OO Blue O Black 1 White 2 Green 3 Orange 4 Red 5 Yellow

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33 Positionning If pt has preferred position let them remain in that position e.g. tripod Repositioning can greatly improve airway patency Manual airway maneuvers can also help open the airway (head tilt-chin lift/ jaw thrust)

34 Positioning

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36 Bag-Mask Ventilation Indicated when the pt’s spontaneous breathing effort is inadequate despite patent airway Can provide adequate oxygenation and ventilation until definitive airway control is obtained Can be as effective as ventilation through ETT

37 Bagging Units Age Volume (ml) Infant 500 Child 1000 Adolescent 20003 sizes: Bag-Valve-Mask Components

38 Testing the bagging unit

40 1-Delevery oxygen by pure ambo bag : 16% - 21%How much is Oxygen Delivered? 1-Delevery oxygen by pure ambo bag : 16% - 21%

41 2- Ambo bag plus Oxygen : 40-60%

42 3- Ambo bag with reservoir bag plus oxygen > 90%

44 Non-Rebreather Mask Range 80-95% Indications ContraindicationsDelivery of high FiO2 Contraindications Apnea Poor respiratory effort Used at 10 to 15 L/min

45 Monitor effectiveness of VentilationVisible chest rise with each breath SpO2 ETCO2 HR BP Pt responsiveness Air entry on auscultation

46 If ventilation is not effective…Reposition pt. Reposition airway. OPA. Verify proper mask size and placement Suction airway Check O2 source and flow Check bag and mask for function/leaks Treat gastric inflation

47 Indications for intubationRespiratory distress Apnea Upper airway obstruction or the potential to develop upper airway obstruction Actual or potential decrease in airway protection (compromised neurological function) Inadequate ventilation and/or oxygenation

48 Preparing for IntubationAppropriate ETT for >1 yo: (age/4) + 4 Term infant: ID 6 mo: ID 1 yo: ID Cuffed ETT’s for pt’s > 8 yo If you anticipate need for high PEEP or PIP (peak inspiratory pressure) may want to use cuffed ETT with <8 yo. Use ½ size smaller ETT. Remember SOAPME

49 SOAPME Suction equipmentOxygen: O2 flowmeter, preoxygenate 2-3 min, manual resuscitator bag with mask Airway equipment: ETT, stylet, syringe (cuffed ETT), laryngoscope and blade, lubricating gel, OPA Position, pharmacy, personnel: supine, rolls for positioning, bed height up Monitors ETCO2 detector

50 Positive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.[1] The two types of PEEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic PEEP (PEEP caused by a non-complete exhalation). Pressure that is applied or increased during an inspiration is termed pressure support. Complications Decrease in systemic venous return Pulmonary barotrauma can be caused. Pulmonary barotrauma is lung injury that results from the hyperinflation of alveoli past the rupture point. Increased intracranial pressure — In people with normal lung compliance, PEEP may increase the intracranial pressure (ICP) due to an impedance of venous return from the head.[7] Renal functions and electrolyte imbalances, due to decreased venous return metabolism of certain drugs are altered and acid-base balance is impeded.[8]

51 “BURP” “External Laryngeal Manipulation”Backward, Upward, Rightward Pressure: manipulation of the trachea 90% of the time the best view will be obtained by pressing over the thyroid cartilage 90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here. “BURP”-backwards, upwards, right, pressure May help with difficult intubation

52 Using The Miller Blade Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis

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55 Post-Intubation ETCO2 assessment for confirmation of placementAuscultation for bilateral air entry Placement of ETT documented ETT secured with tapes CXR to confirm placement Place pt on ventilator

56 Suctioning ETT Suction frequency depends on ETT size and pt needs:4.0 i.d. and smaller- a minimum of Q8H unless otherwise ordered 4.5 i.d. and greater- prn or as ordered Suction depth should only be 0.5 cm past the end of ETT Determine suction depth by using suction guide or match number on catheter to number on ETT and advance 0.5 cm.

57 Selecting suction catheterUse largest size that can pass easily down the ETT Ideally not larger than half the diameter of ETT to avoid causing atelectasis

58 Instillation Normal saline unless otherwise orderedShould occur prn not routinely Recommended amounts: *total volume is especially important to limit and document in infants and small children Age Volume < 1 yo* mL 1-12 yo mL 13-18 yo mL

59 Closed Suction Ensure suction is on and set appropriatelyEnsure bagging unit attached to O2, adequate flow, and intact Attach sterile syringe with appropriate instillation solution to instillation port Securely hold ETT with one hand and insert catheter to appropriate depth with the other Apply continuous suction while slowly withdrawing the catheter Flush catheter by instilling into instillation port while applying suction Allow pt to re-oxygenate at least 30 sec between passes

60 Back-up Plan Can’t ventilate or basics not workingConsider adjuncts (OPA/NPA/positioning) Intubation? Can’t intubate Rescue devices Can’t rescue Surgical procedure

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62 Basics Positioning Adjuncts OPA - good choice if toleratedNPA - easy to tear mucosa Effective BVM use is most important skill Get a good seal (two person better) Don’t over ventilate Don’t forget the suction

63 Intubation -PreparationPreoxygenate Monitors - ECG, pulse ox Sellick’s Good basics Equipment selection Miller vs. Mac Cuffed vs. uncuffed ETT size Positioning

64 In general, blind techniques not useful in childrenExist but need practice for proficiency Digital intubation Small work area Blind nasotracheal intubation Tough angles for tube placement Remember anatomic differences Contraindicated until >10 years old

65 Laryngospasm common when extubation is done when the patient is in a semiconscious state extubation should be done in a deep anesthesia or when the protective laryngeal reflex has returned

66 Extubation ensure that the patient is recovering is breathing spontaneously with adequate volumes evaluate the patient's ability to protect his airway by observing whether the patient responds appropriately to verbal commands ensure that the patient is not in a semiconscious state deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration continue to give the patient O2 as required Oxygenate patient with 100 percent high flow O2 for 2 to 3 minutes if secretions are suspected in the tracheobronchial tree, remove them with a suction catheter through the lumen of the endotracheal tube

67 Rescue Devices LMAs (laryngeal mask airway) Combitube

68 LMA Used in any age Easy to place Few complications Contraindications:Gag reflex FBs Airway obstruction High ventilation pressure Does not secure airway

69 Neonate / Infants < 5 kg Children/Small adults 30-50 kgFormula for Children: The combined widths of the patient's index, middle and ring fingers LMA Sizing LMA Size Patient Size 1 Neonate / Infants < 5 kg 1 ½ Infants 5-10 kg 2 Infants / Children kg 2 ½ Children kg 3 Children/Small adults kg 4 Adults kg 5 Large adult >70 kg 6

70 Combitube Two sizes Small (4 to 5.5 feet tall)Regular (over 5.5 feet tall) Not useful in most kids Easy to place Contraindications Gag reflex Esophageal disease Caustic ingestions FBs/Airway obstruction

71 Surgical Airways - CricothyrotomyIndications (only if >10 years old) Failed airway Failed ventilation Predictors of difficulty Previous neck surgery Obesity Hematoma or infection

72 automated external defibrillator AED

73 AED IN CHILDREN Age > 8 years use adult AED Age 1-8 yearsuse paediatric pads / settings if available (otherwise use adult mode) Age < 1 year use only if manufacturer instructions indicate it is safe 73

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78 Heimlich Maneuver On a Child

79 Heimlich Maneuver On an Infant

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81 infant chocking

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83 Clearing the Mouth

84 child chocking

85 CPR Challenges: Perfusion (Kern)Manual CPR provides minimal blood flow to the heart and brain Manual CPR provides less than optimal blood flow to the heart and brain. In fact, Kern et al. writes that the heart typically experiences only about 10-20% of normal blood flow, and the brain only 30-40%. 10% - 20% of normal flow 30% - 40% of normal flow 85

86 ویزینگ: صدایی مداوم و موزیکال و high pitch است که در راههای هوایی کوچک در بازدم شنیده میشود.این صدا را در موارد تنگی راههای هوایی مثل آسم میتوانیم بشنویم. صدای غیر طبیعی دیگر استرایدور است. این صدا هنگام عبور هوا از مجاری بزرگ اکسترا توراسیک مثل نای که تنگ شده باشند ایجاد میشود و مانند صدای سرفه های خشک صدادار همچون پارس سگ میماند. مثل موقعی که میگن طرف خروسک گرفته. گرانتینگ: بازدم صداداری است که به دلیل بسته بودن اپی گلوت ایجاد میشود و در نوزادان مثل ناله کردن میمونهناله يا صداي خرخر مانند بازدمي .