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Pediatric Airway Management
Dr. Shapiro I., PICU
Dec 2003
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EarlyEarly
DefibrillationDefibrillation
Adult Chain of Survival
CPRCPR ALSALSEMSEMS
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Pediatric Chain of Survival
PreventionPrevention ALSALSCPRCPR EMSEMS
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Out-of-Hospital Cardiac Arrest
�SIDS
�Trauma
�Submersion
� Poisoning
�Choking
�Severe Asthma
� Pneumonia
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In-Hospital Cardiac Arrest
�Sepsis
�Respiratory Failure
�Drug Toxicity
�Metabolic Disorder
�Arrhythmias
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PediatricCardiorespiratory Arrests
PediatricCardiorespiratory Arrests
Respiratory
Shock
Cardiac
Respiratory
Shock
Cardiac
10%10%
80%
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Hypoxia and Hypercarbia
Bradycardia
PediatricCardiorespiratory Arrests
PediatricCardiorespiratory Arrests
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Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479
Arrive in ER in Arrive in ER in cardiac arrestcardiac arrest
(N = 80)(N = 80)
Admit PICU(N=43) 54 %
Died in ER(N=37) 46%
Mod Deficit(N=3)
PVS at 12 mos(N=2)
Dead at 12 mos(N=1)
Died in ICU(N=37) 46%
Outcome of cardiac arrest in children
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Survival from Respiratory Arrest
Respiratory Arrest Alone – more than 50% neurologically intactsurvival rate
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Pediatric Chain of Survival
PreventionPrevention ALSALSCPRCPR EMSEMS
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To Simplifythe Message…
EarlyEarly
DefibrillationDefibrillation
With exceptions…
(submersion, trauma, drug overdose)
With exceptions…
(sudden collapse, cardiac history)
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PREVENTION
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Respiratory DistressRespiratory Failure
andRespiratory Arrest
BLS
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Evaluation of Respiratory Performance
�Respiratory Rate and Regularity
� Level of Consciousness
�Color of the Skin and Mucous Membranes
�Respiratory Mechanics
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Respiratory Mechanics
�Head Bobbing
�Nasal Flaring
�Retractions
�Grunting
�Stridor
�Wheezing or Prolonged Exhalation
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Upper Airway Obstruction
turbulence
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Lower Airway Obstruction
turbulence & wheezing
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Anatomy
Children are very different than adults !!!
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Anatomy :
AirwayNoseTongue
Epiglottis Vocal Cords
Larynx
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Anatomy: Larynx
Narrowest point = cricoid cartilage
INFANTADULT
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Physiology
�Tongue - Posterior Displacement
�Tongue – Difficult to Control
�Epiglottis – Difficult to Control
�Vocal Cords – Difficult Intubation
�Tube size relative to Cricoid Diameter
�Small Airway Edema causes High Resistance
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Effect Of Edema
PoiseuillePoiseuille’’ s laws law
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Basic Life Support
A+B
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Two Steps Before…
1. Ensure the Safety of Rescuer and Victim( the scene, gloves, barrier devices)
“Partial” CPR: Is Something Better than Nothing?
2. Stimulate and Check Responsiveness
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Airway
Head Tilt-Chin Lift Jaw Thrust
+ Tongue-Jaw Lift Maneuver (FBAO)
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BreathingCheck Breathing
Look Listen Feel
Recovery Position
Rescue Breathing
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Ventilation withOxygen
� Mouth-to-Mouth ventilation provides only 17% O2
� Indicated to all seriously ill or injured patients even if pCO2 is high
� If Possible – humidify Oxygen
� Use of reduced FiO2 is uncommon
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Devices to Monitor Respiratory Function
�Pulse Oxymetry
�End-Tidal CO2
�Arterial Blood Gas Analysis
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Oxygen Delivery Systems
�Oxygen Mask
�Face Tent
�Oxygen Hood
�Oxygen Tent
�Nasal Canula
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Oropharyngeal Airway
SIZE PROPER POSITION
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Nasopharyngeal Airway
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Nasopharyngeal Airway
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Bag-Mask Ventilation
Proper area for mask application
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Bag-Mask Ventilation
Sellick Maneuver
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Laryngeal Mask
Contraindicated if gag-reflex is intact
Higher success rate
Does NOT protect from aspiration
Difficult to maintain during transport
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Intubation
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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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Tracheal Tube
Children > 2 years:ETT size: (Age+16)/4ETT depth (lip): ETTsize x 3
Children > 2 years:Children > 2 years:ETT size: ETT size: (Age+16)/4(Age+16)/4ETT depth (lip): ETT depth (lip): ETTsize x 3ETTsize x 3
Age kg ETT Length
Newborn 3.5 3.5 93 mos 6.0 3.5 101 yr 10 4.0 112 yrs 12 4.5 12
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Better in younger children with a floppy epiglottis
Straight
Laryngoscope Blades
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Laryngoscope Blades
Better in older children who have a stiff epiglottis
Curved
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Intubation Technique
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Confirmation of ETT Placement
�NO single technique is 100% reliable
�Clinical Confirmation
�Chest X-ray
�CO2 Detection
�Esophageal Detector Devices
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Clinical Confirmation
�Chest rise
�Water vapor seen inside tube
�Breath sounds - lung
�Breath sounds – epigastrium
�O2 Saturation
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Acute Deterioration after Intubation
Acute Deterioration after Intubation
D.O.P.ED.O.P.E:: DDisplacementisplacement
OObstructionbstruction
PPneumothoraxneumothorax
EEquipment failurequipment failure
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Inadequate Improvement after Intubation
� Inadequate Tidal Volume
�Excessive Leak Around The Tube
�Air Trapping and Impaired Cardiac Output
� Leak or Disconnection in Ventilator System
� Inadequate PEEP
� Inadequate O2 Flow from Gas Source
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Percutaneous CricothyrotomyPercutaneous
CricothyrotomyComplete UA Obstruction:
�FBAO
�Severe Orofacial Injuries
�Upper Airway Infections
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See You at Next Week’s Workshop
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