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Respiratory Distress/CriticalAirway
Deb Updegraff, RN, CCRNClinical Nurse SpecialistLPCH Pediatric Intensive Care Unit
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Signs of Respiratory Distress
Tachypnea Tachycardia
Grunting Stridor Head bobbing Flaring Inability to lie
down Agitation
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Continued- Signs and Symptoms ofRespiratory Distress
Retractions Use of Accessory
musclesWheezingSweatingProlonged expirationPulsus paradoxusApneaCyanosis
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Causes of Resp Distress
Infections
Pneumonias
Bronchiolitis
Empyemas
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Causes Cont.
Excessive fluid in the lungPulmonary 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
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Interventions
Comfort measures
Patient position
O2
Diuretics Broncho-dialators
Nasal trumpet
Positive Pressure Chest tube
Intubation
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The Pediatric Airway
Introduction
Anatomy / Physiology
Positioning Adjuncts
Intubation
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Anatomy : Tongue
Large
Loss of tone with sleep, sedation, CNSdysfunction
Frequent cause of upper airwayobstruction
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Anatomy : Larynx
High position
Infant : C 1
6 months: C 3
Adult: C 5-6
Anterior position
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Children are different
Photos : Calvin Kuan
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Anatomy : Epiglottis
Relatively large size in children
Omega shaped Floppy not much cartilage
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Airway Positioning
Sniffing Position
In the child older than 2 years
Towel is placed under the head
Photos: Calvin Kuan
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Photo: Calvin Kuan
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Airway positioning for children
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Airway adjuncts
Nasal airway
Oral airway
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Adjuncts: Oral Airway
Correct sizePhoto: Calvin Kuan
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Nasopharyngeal Airway
Contraindications:
Basilar skull
fracture
CSF leak
Coagulopathy
Length: Nostril to Tragus
Photo: Calvin Kuan
E d t h l t b l
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Endotracheal tube as nasal
airway
A regular ETT
can be cut andused as a
nasal airway
Photo: Calvin Kuan
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Intubation: Indications
Failure to oxygenate
Failure to remove CO2
Increased WOB Neuromuscular weakness
CNS failure
Cardiovascular failure
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Laryngoscope Blades
Macintosh
Miller
Photo: Calvin Kuan
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Intubation Technique
Straight Laryngoscope Bladeused to
pick up the epiglottis
Better in
younger children
with a floppyepiglottis
Photo: Calvin Kuan
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Intubation Technique
Curved Laryngoscope Bladeplaced in the
vallecula
Better in older
children whohave a stiff
epiglottis
Slide: Calvin Kuan
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Anatomy : Larynx
Narrowest point = cricoid cartilage in thechild
Photo: Calvin Kuan
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Intubation
Age kg ETT Length (lip)
Newborn 3.5 3.5 9
3 mos 6.0 3.5 10
1 yr 10 4.0 112 yrs 12 4.5 12
Children > 2 years:ETT size: Age/4 + 4
ETT depth (lip): Age/2 + 12
Slide: Calvin Kuan
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Technique: Intubation
How far
does it go in
?
Photo: Calvin Kuan
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An Airway is designated CRITICAL by any of
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An Airway is designated CRITICAL by any ofthe 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 abnormalitieSGoldenhars, Klipper-Fiell
MacroglossiaBeckwith-Wiedemann, Downs, Achondroplasia
Soft tissue abnormalitiesSubmandiibular masses, epiglottis, hemangiiomas
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Treacher Collins
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Before Mandibular DistractionAfter Mandibular Distraction
Treacher Collins
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Hemangioma
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Pierre Robin
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Goldenhar
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Subglottic stenosis is a narrowing of subglotticairway housed In the cricoid cartilage. This is thenarrowest area in the pediatric airway.
Airway Reconstructive Surgery- Very CommonCritical Airway patient in the PICU
Normal view of trachea
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4 month old with acquired Grade IIISubglottic stenosis from intubation
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Same view: Magnified
Following Cricoid Split Surgical Procedure
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Following Cricoid Split Surgical Procedure
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Preoperative Subglottic View of2 year old with acquired verticle subglotticstenosis
After anterior and posterior grafting and successful decannulation of
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After anterior and posterior grafting and successful decannulation oftracheostomy
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ICU Check list for Critical Airway:
Patients name:
Patients Weight:
-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 arelocated.
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.
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