Transcript The problematic paediatric airway – assessment and management

The Compromised Paediatric
Airway – Assessment and
Management
Dr Vanessa Fludder
Locum Consultant Anaesthetist
Worthing and Southlands Hospitals
Aims
Appreciate differences between adult and
paediatric airways
Recognise symptoms and signs of the
compromised paediatric airway.
Know the common causes,
Be able to initiate management whilst
awaiting senior help.
Differences in the
Adult and Paediatric airway
Differences
 Smaller diameter airway
(and more flexible trachea)
 Higher, more anterior
larynx
 Cone/funnel shaped
larynx
 Prominent Occiput
 More prone to obstruction
Differences
 Smaller diameter
airway
 Higher, more anterior
larynx
 Cone/funnel shaped
larynx
 Prominent Occiput
 More prone to obstruction
 Less likely to choke when
feeding, more difficult to
visualise
 Narrowest point is below
cords
 No need for pillow when
mask
ventilating/intubating
Differences
 High oxygen consumption
(7mls/kg/min)
 Use oxygen reserve more
quickly
 Reduced Functional
residual capacity
 Desaturate more quickly
 Greater chest wall
compliance
 Less efficiency
 Less fatigue resistant
muscle fibres
 Tire more quickly
Other Differences
They cannot tell you what is wrong
They don’t cooperate
Things deteriorate rapidly
Children have parents!
They also get better more quickly!
Basic Rules of Assessment
Urgency of intervention
History, probable diagnosis and natural
history
Investigations for non-emergencies
Practical intervention
History
Onset of symptoms
Duration
Feeding/Dysphagia
Voice change (older children)
Cry – weak or absent
Prematurity/Development
Previous airway problems/anaesthetics
Examination
A B C D E
A -Tracheal tug, recession, accessory
muscles, position, drooling
- Weak or absent cry, stridor, wheeze,
cough
B resp rate, breath sounds, SpO2
Assessment
A B C D E
C heart rate, colour, capillary refill, wet
nappies?
D Drowsy? Irritable? Inconsolable?
E Feeding? Rash/erythema/swelling?
temperature, Exhaustion
Causes of airway obstruction
 Congenital
abnormalities
 Acquired problems
 Acquired
 Inhaled foreign body
 Infection
 Burns
 Trauma
Inhaled foreign body
Most commonly children under 3yrs
Usually a food item
Severely compromised/choking
Relatively stable
CXR
HELP! - ENT surgeon and anaesthetist
Oxygen
Dex/Adren to reduce swelling
Burns
Facial/airway swelling develops quickly
Need to consider intubation if
Facial burns
Singeing of nasal hair or eyebrows
Soot in airway or up nose
Change in voice
Refer to burns unit
Rehydration
Smaller ETT (sux)
Trauma
Post surgical
post tonsillectomy, adenoidectomy
Post intubation
Accidental Injury
Post-tonsillectomy bleeding
Clot in airways
Swelling
Hypovolaemia – concealed loss
Oxygen
Senior ENT surgeon and Anaesthetist
Rehydrate and X-match (hartmann’s, saline or colloid)
Post-intubation
Ex-prems
Sub-glottic stenosis
Accidental Injury
Facial fractures
Blood
Tissue
Bone framents
Teeth
Laryngotracheal
Blunt or penetrating – rare in children
Sub-cutaneous air
Beware NAI
Infections
Bronchiolitis
Laryngotracheobronchitis (croup)
Epiglottitis
Laryngeal papillomas
Diptheria
Bronchiolitis
Laryngotracheobronchitis
(Croup)
Common-ish
(3% children <6yrs)
URTI with characteristic barking cough
Gradual deterioration
Oxygen (humidified)
Adrenaline nebs and steroids
Rarely need intubation
Visualisation OK
Smaller ETT
Extubate when leak around ETT (3-5 days)
Epiglottitis
Uncommon since Hib vaccine
Unwell, symptoms progress rapidly
Dysphagia, drooling, stridor, posturing
HELP
Oxygen
Heliox/Adrenaline Nebs
‘Don’t Touch the Baby’
Congenital Abnormalities
Congenital
 Down’s Syndrome
 Pierre Robin
 Treacher Collins
 Goldenhar’s
 Hurler’s
 Cleft Palate
 Marfan’s
 Klippel Feil
 Laryngomalacia
 Tracheomalacia
 Subglottic stenosis
 Cysts
 Congenital tumours
Management
HELP!
Senior Anaesthetist
Senior ENT surgeon
Oxygen (high concentration)
Humidification/Heliox
Nebulised Adrenaline (0.4mls/kg 1 in 1000, max 5mg)
Steroids (0.3-0.6mg/kg dexamethasone or budesonide nebs
1mg)
Lastly
 Remember the whole
child – not just the
airway!
 Be nice to the
parents!
Questions ???