Transcript Critical Airway/Respiratory Distress
Respiratory Distress/Critical Airway Deb Updegraff, RN, CCRN Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit
Signs of Respiratory Distress Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation
Continued- Signs and Symptoms of Respiratory Distress
•Retractions • Use of Accessory muscles •Wheezing •Sweating •Prolonged expiration •Pulsus paradoxus •Apnea •Cyanosis
Causes of Resp Distress
Infections Pneumonias Bronchiolitis Empyemas
Causes Cont.
Excessive fluid in the lung Pulmonary edema (CHF) Excessive fluid or air in the pleural space Pneumothorax, pleural effusions Upper airway obstructions swollen airway, large tonsils, malacias, Lower airway obstructions asthma
Interventions
Comfort measures Patient position O2 Diuretics Broncho-dialators Nasal trumpet Positive Pressure Chest tube Intubation
The Pediatric Airway
Introduction Anatomy / Physiology Positioning Adjuncts Intubation
Anatomy : Tongue
• • • Large Loss of tone with sleep, sedation, CNS dysfunction Frequent cause of upper airway obstruction
Anatomy : Larynx
• High position • • • Infant : C 1 6 months: C 3 Adult: C 5-6 • Anterior position
Photos : Calvin Kuan
Children are different
Anatomy : Epiglottis
Relatively large size in children Omega shaped Floppy – not much cartilage
Photos: Calvin Kuan
Airway Positioning
“Sniffing Position” In the child older than 2 years Towel is placed under the head
Photo: Calvin Kuan
Airway positioning for children <2yrs
Photo: Calvin Kuan
Photo: Calvin Kuan
Airway adjuncts
Nasal airway Oral airway
Adjuncts: Oral Airway
Photo: Calvin Kuan
Correct size
Nasopharyngeal Airway
Length: Nostril to Tragus Contraindications:
Basilar skull fracture
CSF leak Coagulopathy
Photo: Calvin Kuan
Endotracheal tube as nasal airway
A regular ETT can be cut and used as a nasal airway Photo: Calvin Kuan
Intubation: Indications
Failure to oxygenate Failure to remove CO 2 Increased WOB Neuromuscular weakness CNS failure Cardiovascular failure
Photo: Calvin Kuan
Laryngoscope Blades
Macintosh Miller
Intubation Technique
Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis
Photo: Calvin Kuan
Intubation Technique
Better in older children who have a stiff epiglottis Curved Laryngoscope Blade – placed in the vallecula
Slide: Calvin Kuan
Anatomy : Larynx
Narrowest point = cricoid cartilage in the child Photo: Calvin Kuan
Intubation
Slide: Calvin Kuan
Age kg ETT Length (lip) Newborn 3 mos 1 yr 2 yrs 3.5
6.0
10 12 3.5
3.5
4.0
4.5
9 10 11 12 Children > 2 years: ETT depth (lip): Age/2 + 12
Photo: Calvin Kuan
Technique: Intubation
How far does it go in ?
An Airway is designated CRITICAL by any of the following Criteria
•Airway status post reconstruction surgery •Difficult airway in the OR per anesthesia •Patients with syndromes recognized with difficult airways
Micrognathia- Pierre Robin, Treacher Collins Cervical Spine abnormalitieS
•Goldenhars, Klipper-Fiell •Macroglossia •Beckwith-Wiedemann, Downs, Achondroplasia •Soft tissue abnormalities •Submandiibular masses, epiglottis, hemangiiomas
Treacher Collins
Treacher Collins
Before Mandibular Distraction After Mandibular Distraction
Hemangioma
Pierre Robin
Goldenhar
Airway Reconstructive Surgery- Very Common Critical Airway patient in the PICU Subglottic stenosis is a narrowing of subglottic airway housed In the cricoid cartilage. This is the narrowest area in the pediatric airway.
Normal view of trachea
4 month old with acquired Grade III Subglottic stenosis from intubation
Same view: Magnified
Following Cricoid Split Surgical Procedure
Preoperative Subglottic View of 2 year old with acquired verticle subglottic stenosis
After anterior and posterior grafting and successful decannulation of tracheostomy
Patient’s Weight: Patient’s name: ICU Check list for Critical Airway:
-Room ready with intubation box.
-Critical Airway sign posted at HOB.
-Continuous infusion meds ordered (i.e. benzodiazepines
, Opioids, muscle relaxants, and others).
-Antibiotics and anti-reflux meds ordered.
Sign-out has occurred and is documented.
-ET tube is secured.
-Chest x-ray obtained which is used to determine where the ET tube and CVL are located.
Patient to have arm restraints ordered and placed.
Code Pack in the room.
Code sheet completed in the room.
My Doctor sheet completed and at the head of the bed.