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:

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Basilar skull fracture

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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:

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-Room ready with intubation box.

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-Critical Airway sign posted at HOB.

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-Continuous infusion meds ordered (i.e. benzodiazepines

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, Opioids, muscle relaxants, and others).

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-Antibiotics and anti-reflux meds ordered.

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Sign-out has occurred and is documented.

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-ET tube is secured.

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-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.

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Code Pack in the room.

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Code sheet completed in the room.

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My Doctor sheet completed and at the head of the bed.