Critical Airway Deb 9.07

8/3/2019 Critical Airway Deb 9.07

1/48

Respiratory Distress/CriticalAirway

Deb Updegraff, RN, CCRNClinical Nurse SpecialistLPCH Pediatric Intensive Care Unit


2/48

Signs of Respiratory Distress

Tachypnea Tachycardia

Grunting Stridor Head bobbing Flaring Inability to lie

down Agitation


3/48

Continued- Signs and Symptoms ofRespiratory Distress

Retractions Use of Accessory

musclesWheezingSweatingProlonged expirationPulsus paradoxusApneaCyanosis


4/48

Causes of Resp Distress

Infections

Pneumonias

Bronchiolitis

Empyemas


5/48

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


6/48


7/48


8/48

Interventions

Comfort measures

Patient position

O2

Diuretics Broncho-dialators

Nasal trumpet

Positive Pressure Chest tube

Intubation


9/48

The Pediatric Airway

Introduction

Anatomy / Physiology

Positioning Adjuncts

Intubation


10/48

Anatomy : Tongue

Large

Loss of tone with sleep, sedation, CNSdysfunction

Frequent cause of upper airwayobstruction


11/48

Anatomy : Larynx

High position

Infant : C 1

6 months: C 3

Adult: C 5-6

Anterior position


12/48

Children are different

Photos : Calvin Kuan


13/48

Anatomy : Epiglottis

Relatively large size in children

Omega shaped Floppy not much cartilage


14/48

Airway Positioning

Sniffing Position

In the child older than 2 years

Towel is placed under the head

Photos: Calvin Kuan


15/48

Photo: Calvin Kuan


16/48

Airway positioning for children


17/48


18/48

Airway adjuncts

Nasal airway

Oral airway


19/48

Adjuncts: Oral Airway

Correct sizePhoto: Calvin Kuan


20/48

Nasopharyngeal Airway

Contraindications:

Basilar skull

fracture

CSF leak

Coagulopathy

Length: Nostril to Tragus

Photo: Calvin Kuan

E d t h l t b l


21/48

Endotracheal tube as nasal

airway

A regular ETT

can be cut andused as a

nasal airway

Photo: Calvin Kuan


22/48

Intubation: Indications

Failure to oxygenate

Failure to remove CO2

Increased WOB Neuromuscular weakness

CNS failure

Cardiovascular failure


23/48

Laryngoscope Blades

Macintosh

Miller

Photo: Calvin Kuan


24/48

Intubation Technique

Straight Laryngoscope Bladeused to

pick up the epiglottis

Better in

younger children

with a floppyepiglottis

Photo: Calvin Kuan


25/48

Intubation Technique

Curved Laryngoscope Bladeplaced in the

vallecula

Better in older

children whohave a stiff

epiglottis

Slide: Calvin Kuan


26/48

Anatomy : Larynx

Narrowest point = cricoid cartilage in thechild

Photo: Calvin Kuan


27/48

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


28/48

Technique: Intubation

How far

does it go in

?

Photo: Calvin Kuan


29/48

An Airway is designated CRITICAL by any of


30/48

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


31/48

Treacher Collins


32/48


33/48

Before Mandibular DistractionAfter Mandibular Distraction

Treacher Collins


34/48

Hemangioma


35/48


36/48

Pierre Robin


37/48

Goldenhar


38/48


39/48

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


40/48


41/48

4 month old with acquired Grade IIISubglottic stenosis from intubation


42/48

Same view: Magnified

Following Cricoid Split Surgical Procedure


43/48

Following Cricoid Split Surgical Procedure


44/48

Preoperative Subglottic View of2 year old with acquired verticle subglotticstenosis

After anterior and posterior grafting and successful decannulation of


45/48

After anterior and posterior grafting and successful decannulation oftracheostomy


46/48

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.


47/48


48/48

Documents

Critical Airway Deb 9.07