Transcript Slide 1
Pediatric Airway Management دکتر مهرزاد آرتنگ رییس اداره اورژانس Pediatric Cardiopulmonary Arrests 10% 10% Respiratory Shock Cardiac 80% In most infants and small children respiratory arrest precedes cardiac arrest. Characteristics of Newborn Respiratory System 1. Infant lung is a unique structure not a mini- adult lung 2. Airways, distal lung tissue and pulmonary capillary bed continue to grow and develop after birth 3. Alveoli development complete and adult anatomy by 8-10 years of age 4. Ossification of ribs and sternum complete by 25 years of age Nose • Obligatory nasal breathing • Poor tolerance to obstruction Tongue • Relatively Large • Neck extension may not relieve obstruction Head • Relatively large • Anterior flexion may cause airway obstruction Epiglottis • Relatively large and U- shaped • More susceptible to trauma • Forms more acute angle with vocal cords Cricoid • Narrowest portion of airway • ↑ resistance with airway edema or infection • Acts as “cuff” during tracheal intubation Effect Of Edema If radius is halved, resistance increases 16 x 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 WOB • Weak resp muscles Regulation of Breathing • Response to ↓ O2/ ↑ CO2 minimal • Tolerates hypoxia poorly Assessment • 30 second rapid cardiopulmonary assessment is structured around ABC’s. • Airway • Breathing • Circulation Airway • Airway must be clear and patent for successful ventilation. • Position • Clear of foreign body • Free from injury • Intubate if needed “Patients do not die from lack of intubation they die from lack of oxygenation” 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. Breathing • Breathing is assessed to determine the child’s ability to oxygenate. • Assessment: • Respiratory rate • Respiratory effort • Breath sounds • Skin color Impending Respiratory Failure • Respiratory rate less than 10 or greater than 60 is an ominous sign of impending respiratory failure. Prearrest. s 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? Breathing • • • • RR Effort Airway and lung sounds SpO2 RR • Best to evaluate prior to hands-on assessment • Excitement, 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 (45) 22-34 Signs of Respiratory Distress • • • • • • • Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Agitation • • • • • • • Retractions Access muscles Wheezing Sweating Prolonged expiration Apnea Cyanosis Lung Sounds • • • • • • Normal Wheezes Rales (Crackles) Stridor Rhonchi Pleural Rub • • • • • • Listen on every patient End of Expiration End of Inspiration During both phases Expiration End of Inspiration Airway Management • Simple things to improve airway patency • Suction nose and oropharynx • child/ allow child to assume position of comfort • head-tilt-chin lift/ jaw thrust • Use airway adjuncts - NPA/ OPA Oral & Naso pharyngeal Suctioning • Clean 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 هیپوکس ی و ساکشن • برای جلوگیری از این مشکل ،ساکشن کردن را به 15ثانیه در بالغین و 5ثانیه در اطفال محدود کنید . Oral Pharyngeal Airways (OPA) • Only for use in UNCONSCIOUS pt with no intact cough/gag reflex • Never tape in place Choosing correct OPA SIZE 000 OO O 1 2 3 4 5 COLOUR Violet Blue Black White Green Orange Red Yellow Nasopharyngeal Airways • Can use in conscious/ semi-conscious pt Contraindications: • Basilar skull fracture • CSF leak • Serious midline facial fractures If these don’t work… • Pt may require more advanced interventions to establish a patent airway • CPAP CPAP uses mild air pressure to keep an airway open. CPAP typically is used for people who have breathing problems …. Continuous positive airway pressure, a particular type of ventilation (breathing) therapy • Intubation • ……. 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) Positioning 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 Bagging Units • 3 sizes: Age Volume (ml) Infant Child 500 1000 Adolescent Bag-Valve-Mask Components 2000 Testing the bagging unit 1-Delevery oxygen by pure ambo bag : 16% - 21% Two person BMV Non-Rebreather Mask • Range 80-95% • Indications • Delivery of high FiO2 • Contraindications • Apnea • Poor respiratory effort –Used at 10 to 15 L/min Monitor effectiveness of Ventilation • • • • • • • Visible chest rise with each breath SpO2 ETCO2 HR BP Pt responsiveness Air entry on auscultation 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 Indications for intubation • Respiratory 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 Preparing for Intubation • Appropriate ETT for >1 yo: (age/4) + 4 Term infant: 3.0-3.5 ID 6 mo: 3.5-4.0 ID 1 yo: 4.0-4.5 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 SOAPME Suction equipment Oxygen: 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 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 noncomplete 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 acidbase balance is impeded.[8] “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 Using The Miller Blade Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis Post-Intubation • • • • • • ETCO2 assessment for confirmation of placement Auscultation for bilateral air entry Placement of ETT documented ETT secured with tapes CXR to confirm placement Place pt on ventilator 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. Selecting suction catheter • Use largest size that can pass easily down the ETT • Ideally not larger than half the diameter of ETT to avoid causing atelectasis Instillation • Normal saline unless otherwise ordered • Should occur prn not routinely • Recommended amounts: Age < 1 yo* 1-12 yo 13-18 yo Volume 0.5-1.0 mL 0.5-3.0 mL 0.5-5.0 mL *total volume is especially important to limit and document in infants and small children Closed Suction • Ensure suction is on and set appropriately • Ensure 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 Back-up Plan • Can’t ventilate or basics not working • Consider adjuncts (OPA/NPA/positioning) • Intubation? • Can’t intubate • Rescue devices • Can’t rescue • Surgical procedure Basics • Positioning • Adjuncts • OPA - good choice if tolerated • NPA - 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 Intubation -Preparation • Preoxygenate • Monitors - ECG, pulse ox • Sellick’s • Good basics • Equipment selection • Miller vs. Mac • Cuffed vs. uncuffed • ETT size • Positioning In general, blind techniques not useful in children Blind Techniques • • • Exist 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 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 • ensure that the patient is recovering Extubation is breathing spontaneously with adequate volumes • evaluate the patient's ability to protect his airway by observing • ensure that the patient is not in a whether the patient responds appropriately to verbal commands semiconscious state • 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 • deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration • continue to give the patient O2 as required Rescue Devices • LMAs (laryngeal mask airway) • Combitube LMA • • • • Used in any age Easy to place Few complications Contraindications: • Gag reflex • FBs • Airway obstruction • High ventilation pressure • Does not secure airway LMA Sizing Formula for Children: The combined widths of the patient's index, middle and ring fingers LMA Size Patient Size 1 Neonate / Infants < 5 kg 1½ Infants 5-10 kg 2 Infants / Children 10-20 kg 2½ Children 20-30 kg 3 Children/Small adults 3050 kg 4 Adults 50-70 kg 5 Large adult >70 kg 6 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 Surgical Airways - Cricothyrotomy • Indications (only if >10 years old) • Failed airway • Failed ventilation • Predictors of difficulty • Previous neck surgery • Obesity • Hematoma or infection automated external defibrillator AED • Age > 8 years • use adult AED • Age 1-8 years • use paediatric pads / settings if available (otherwise use adult mode) • Age < 1 year • use only if manufacturer instructions indicate it is safe Title Text • Heimlich Maneuver On a Child • Heimlich Maneuver On an Infant • infant chocking Clearing the Mouth child chocking CPR Challenges: Perfusion (Kern) Manual CPR provides minimal blood flow to the heart and brain 10% - 20% of normal flow 30% - 40% of normal flow ویزینگ: صدایی مداوم و موزیکال و high pitchاست 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 مثل ناله کردن میمونهناله يا صداي خرخر مانند بازدمي . اپی گلوت ایجاد میشود و در نوزادان