Developed By Alicia Kleinhans BSN RN CEN CCRN Slide 2 Objectives
List 3 unique features of pediatric airway which are necessary to
recognize for airway management Describe the main difference
between ventilation and perfusion and list 2 ways this can cause
hypoxemia Name at least 4 clinical signs of respiratory distress
and respiratory failure List at least 3 causes of respiratory
distress in pediatric patients and describe 2 methods of treatment
Name at least 3 indicators for intubation Describe the 6 steps
necessary for intubating a pediatric patient List 5 steps in a
systematic approach to xray interpretation Slide 3 Airway is the
key to success Slide 4 Slide 5 Normal Anatomy Normal Chest Anatomy
Some things the same with adult vs Peds ie Tidal Volume 4.5-7ml/kg
Most things different Slide 6 How does Pediatric airway differ from
adults Slide 7 Narrowing of airway Slide 8 Anatomical Differences o
Tongue proportionally larger o Epiglottis floppy, U shaped o Larynx
more anterior and high C2 in neonate, C3-4 in child, C5-6 in adult
o Shorter - newborn trachea 5cm; 18 month old 7cm o Narrower
narrowest point at cricoid ring, uncuffed tubes1 week Pre or Post
ductal important S&S cyanosis, tachypnea, tachycardia, CHF
Management Prostaglandin O2 can be Bad surgical repair Slide 66
Coarctation of the aorta Slide 67 Tetralogy of Fallot (cyanotic)
Signs & Symptoms Low O2 Sats TET spells Boot shaped heart Right
to Left shunt Management Prostaglandin O2 wont help 2 staged
surgical repair Blalock- Taussig shunt and total repair Slide 68
TET Spells Slide 69 Transposition of Great Arteries (cyanotic)
Signs & Symptoms Cyanosis, Tachypnea, Retractions Poor
feeding/FTT With VSD, not recognized until CHF Management
Prostaglandin O2 wont help Atrial septostomy Arterial switch Slide
70 Slide 71 Airway adjuncts Conscious Unconscious Conscious patient
Nasopharyngeal Airway/Nasal Trumpet Length=distance from nares to
meatus of ears Unconscious patient Oropharyngeal Airway/OPA Holds
tongue out of the way Length=distance from corner of mouth to
meatus of ears Slide 72 Oxygen delivery Nasal Cannula Venturi Mask
Non rebreather (NRB) High flow Nasal Cannula Slide 73 Positive
Pressure Delivery Basics BVM BiPAP/ CPAP Definitive Airways LMA
King Tube ETT: nasal, oral, retrograde, cricothyroidotomy
Transtracheal Jet Insufflation Slide 74 Indicators for Intubation
Ventilatory Support Tachypnea and increased WOB Inadequate rate,
depth Protection/Patency of Airway GCS Ventilatory Support Can't
Maintain Ventilation/Oxygenation SaO2 40% PaCO2 >55 if baseline
is normal, or >10 increase from baseline Respiratory Rate
Expected decline in Clinical Status Deterioration/Impending
Compromise Transport Airway protection during procedures (ie.
endoscopy) Slide 76 Protection patency of airway Can't Protect
Airway Gag reflex is absent in up to 37% of population, so a poor
predictor of airway protection Can they talk? Can they swallow and
manage secretions Slide 77 Other Reasons: Supply/Demand imbalance
of perfusion. Mechanical Obstruction, or need for Core Rewarming,
Inadequate respiratory compensation for met acidosis CO2
should=(1.5 [HCO3-] + 8) 2 Slide 78 LMA Cuff device provides
sufficient seal for PPV Indication for Use: Endotracheal intubation
not desired Emergent mask ventilation not possible/adequate
Intubation fails Slide 79 King Tube Supraglottic airway Proximal
cuff seals nasopharynx and oropharynx Distal cuff seals esophagus
Smallest tube for 12kg patient Indication for Use: Same as LMA
Suspected c-spine Slide 80 Endotracheal Tube Made from polyvinyl
chloride with radiopaque line from top to bottom Cuffed vs Uncuffed
Hole at beveled, distal end Murphys Eye External insertion depth
marks Sizes range 2.5-8, estimate pinky finger or (age/4) +4 Slide
81 Stylette/ Bougie StyletteBougie Removed after ETT in place ETT
threaded over Advanced through cords Semi-rigid with bent tip
Removed after intubation Placed inside ETT prior to placement
Bendable Rod Slide 82 Slide 83 Nasotracheal Intubation Indications
Conscious patient Status epilepticus Anaphylaxis Anatomy
Contraindications Apnea Basilar skull fracture/ facial trauma
Bleeding disorders Complications Esophageal placement Epistaxis
Vagal stimulation Trauma to vocal cords/paralysis Injury to nasal
turbinates Slide 84 How do you intubate this guy? Slide 85
Orotracheal Intubation Indications Definitive airway protect airway
GCS Slide 86 Assessing airway for difficulty ASA classification
Malampati scores History Obvious trauma or deformities Slide 87
Position patient Slide 88 Look for landmarks Slide 89 Slide 90
Retrograde Intubation Indications Conscious patient
Difficult/Unable to intubate Suspected c-spine Contraindications
Laryngotracheal disease Anatomy Coagulopathy Complications False
passage of guidewire Bleeding/ hemoptysis larygospasm Slide 91
Retograde intubation Slide 92 Fiberoptic and Glidescope Slide 93
Trachlight Slide 94 Cricoidectomy Not typically used in pediatrics
Indications Unable to intubate Airway obstruction Trauma to
face/upper airway Unstable c-spine Contraindications Coagulopathy
Anatomy Lack of practitioner skill Complications Subglottic
stenosis Laceration of esophagus Injury to laryngeal structures Air
leak syndrome Slide 95 Slide 96 Transtracheal Jet Insufflation
Indications Unable to intubate Contraindications Anatomy
Complications Perforation of esophagus Bleeding Subcutaneous
emphysema Air leak syndrome Hypoventilation Expiratory obstruction
Slide 97 Slide 98 Tracheostomies This is your airway Slide 99 Slide
100 To RSI or Not To RSI, that is the question. Slide 101 6 Ps of
RSI Preparation Preoxygenation Pretreatment Paralysis Placement
Post-intubation Slide 102 Preparation Assess for difficulty Prepare
drugs Patent IV Prepare Equipment ETT Miller blade/light Oxygen and
Suction (on and working) Co2 detector Position patient (roll) Slide
103 Difficulty? Slide 104 Preoxygenate and Pretreat 100% O2 for 5
minutes Non-rebreather vs BVM Want sats of 100% Use of atropine?
(hypoxia - bradycardia, masking) Give analgesic Morphine 0.1mg/kg
not with asthma Fentanyl 1mcg/kg Give sedative Versed 0.1mg/kg
Ketamine 0.5-2mg/kg Propofol 0.5-1mg/kg Slide 105 Paralysis
Non-depolarizing neuromuscular blockade only! Vecuronium 0.1mg/kg
Rocuronium 1mg/kg (Sugammadex) Gantacurium new shorter duration
Emesis cannot occur Wait until no movement Slide 106 Depolarizing
Neuromuscular Blockade Persistent agonist at nicotinic receptor
sites Fasciculations Short duration of paralysis (5-10min) Side
effects are many Non-Depolarizing Neuromuscular Blockade
Competitive antagonist at nicotinic receptors Longer duration of
paralysis (30-40min) Virtually no side effects Slide 107
Depolarizing Problems associated with depolarizing neuromuscular
blockade include Myalgia (muscle soreness), Hyperkalemia Increased
ICP Atypical interactions in some individuals Depolarization will
induce the release of potassium from skeletal muscle Malignant
hyperthermia is rare but lethal Recovery cannot be accelerated by
administering medications Slide 108 Non-depolarizing Recovery from
paralysis with non-depolarizing neuromuscular blockers can be
accelerated by administration of a cholinesterase inhibitor (ie
Pyridostygmine). These agents cause muscle paralysis in a predicted
sequence (and recovery in the opposite sequence): muscle of fine
movement (eye, jaw, larynx) limbs trunk intercostals diaphragm
Slide 109 Placement Hold all ventilations unless sats fall below
90% Watch for bradycardia Using Miller/straight blade, sweep tongue
to left, go past the epiglottis and lift without rocking Sellicks
maneuver aka cricoid pressure Visualize cords and pass through
Confirm placement Slide 110 Slide 111 Post intubation management
Secure the tube Initiate mechanical ventilation Insert naso- or
orogastric tube Monitor patient continuously Slide 112 Slide 113
Gold Standard: Clinical Exam Look for symmetrical chest rise and
misting in tube Auscultation of epigastrum Auscultation of
bilateral lung fields including axillae Change in Skin
Color/Improvement in patient Slide 114 Oxygen Saturations Sensitive
to light movement perfusion Oxygen Saturation PaO2 90%60 75%40
50%27 Slide 115 CO2 Detectors Depend on perfusion Capnography Many
EMS have in Ambulances Useful for trending over periods of time Can
lose reading Studies finds 70% accuracy in determining placement in
post cardiac arrest pt Colorimetric CO2 detector Yellow=Yes
Purple=Problem May take 4-6 ventilations before color change Slide
116 Esophageal Detector Bulb shape Squeeze then place on end of ETT
If self-inflates, tracheal intubation due to rigid cricoid
cartilage Studies finds 99- 100% accurate, more accurate than ETCO2
(70-86%) Slide 117 Chest xray Placement- tip of ETT should be no
lower than 1-2 cm above the carina No higher than 1 st rib Remember
1cm of movement in adult ok, 1cm of movement in infant or
child=extubated Slide 118 Slide 119 Break for Lunch Slide 120 Slide
121 Remember in each case Proper technique- ability to see
important landmarks Orientation of the film- left or right marked
Good inspiratory effort Recognize film artifacts Systematic
Approach Pertinent clinical history Slide 122 Top to bottom
Determine orientation- clavicles Airway Inspiratory vs Expiratory-
count ribs (10 above diaphragm) Heart shape, size 50% or less,
aortic knob Clear costo-phrenic angle/ cardiophrenic angle
Pulmonary vasculature, Fluid or Air Fractures/Trauma Slide 123
Mnemonic A. Airway and adenopathy B. Bones and breast shadows C.
Cardiac silhouette. D. Diaphgram E. Everything else F. Fields Slide
124 Normal Chest Trachea Midline Thymus- water dense mass in
superior mediastinum. Usually wavy contour. Bilobed but not always
symmetrical. Heart- water dense with apex to left. Occupies about
50% of chest at widest point. Aortic knob seen through thymus on
left Pulmonary vessels- seen best on lateral view. Extend to mid
lung tapering gradually Lungs- uniformly aerated. Appear black Bony
structures- ribs, upper thoracic vertebral bodies, scapulae and
clavicles Diaphragm- right and left equal Slide 125 Normal Chest
Slide 126 Slide 127 Group Activity Slide 128 Tension Pneumothorax
Slide 129 Pleural Effusion Slide 130 Pneumopericardium vs
Pericardial Effusion Slide 131 Pneumomediastinum Slide 132
Hydrocarbon Aspiration vs Pneumonia Slide 133 Slide 134 4 month old
premature infant Slide 135 More history Ex 33 weeker. Required BVM
resuscitation at birth. 48 hours of ventilator and two weeks total
in NICU until feedings were adequate Hospitalized at 2 months for
severe bronchiolitis Lives with mother who smokes and 4 year old
sibling who attends day care Slide 136 Physical exam What do you
want to know?? Slide 137 Which is the most likely diagnosis?
Asthma/ RAD Bronchiolitis Slide 138 Bronchiolitis Although this is
his second episode of wheezing, a diagnosis of asthma in a child
this young is unlikely Most likely Viral bronchilotis Why is this
most likely? What treatment? Slide 139 15 month old Wheezing in
morning and worsened throughout the day Not taking fluids or eating
Slide 140 Physical Exam General Vitals Head to toe Slide 141 What
is going on? Possible diagnosis What do you need to do? Slide 142
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Nursing (1 st ed.). Philadelphia, PA: W.B. Saunders Waldrop, Julee
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