Anatomy

Higher, more anterior position of the glottic opening

Relatively larger tongue in the infant which lies between the mouth and glottic opening

Larger and more floppy epiglottis in the child Cricoid ring is the narrowest portion Smaller cricothyroid membrane Larger occiput Obstruct easier from noxious stimuli, work of

breathing in a crying child increases 32 fold.

Note the Ω shapeUnformed hyoepiglottic ligament

Can not compress as easy with a mac blade to move epiglottis indirectly

Epiglottitis

Physiology Basal oxygen consumption is twice adult

values (>6ml/kg/minute versus 3ml/kg/min for adults)

Proportionally smaller functional residual capacity as compared with adults (at apnea 10% versus 40%).

Shortened period of protection from hypoxia for equivalent preoxygenation time.

Need to keep SPO2 above 90%

Equipment/ Medications

Use the Braslow tape at all times!!!!We can all do the math however, the tape

decreases the time have to take to perform calculations and can utilize that time on assessment and treatment.

Decreases medication errors.Inappropriate sized oral airways can act to

increase obstructionToo small of a laryngoscope blade can waste

time trying to visualize the glottic opening.

Equipment

Cuffed vs. uncuffed: studies show no increase in adverse effects if the pressure in the cuff can be monitored.

Uncuffed are safer for EMS providers to use unless patient requires high mean airway pressures.

If a cuffed ETT is used only inflate if leaking is noted around the cuff.

Deakers TW, Reynolds G, Stretton M, et. Al. Cuffed ETT in pediatric intensive care. L Pediatr 1994; 125:57-62Khine HH, Corddry DH, Kettrick RG, et al. Comparrison of cuffed and uncuffed ETT in young children during general anesthesia. Anesthesiology 1997; 86:627-631

Intubation Process

Position patient

External canal lies just anterior to the shoulder

Place OPAPre treat with atropine, dose from BraslowVersed per tapeSucc’s at 2mg/kg due to faster metabolic rateApply Sellick’s manueverMaintain SPO2 at 90% though procedure

RSI

Intubation Continued

Straight blade is preferred to manipulate the epiglottis directly.

Use ETT sized by tape.Visualize placement through cords.Place ETCO2 (use adult size if over 15kg), check

for waveform.Lung sounds, epigastric sounds.Secure and place c-collar.

Post-Intubation Small movements in kids are big movements

in their airway and the c-collar is highly recommended.

NG tube to relieve distension Sedate as needed, continue paralysis Monitor ETCO2, SPO2,assess breath sounds

often.

Plan B, C,D

BVM King OPA Surgical Bougie if ETT > 6.0

You arrive on scene to find a 4 year old male in the care of his mother. Mom reports the child has become progressively more ill over the last 24 hours. You observe the child drooling, sitting forward in a tripod position and refuses to sit back. He feels warm to the touch, RR: 36 with mild retractions, HR: 130, Skin: Pink, warm and dry with refill < 2 seconds, palpable peripheral pulses. He appears ill and talks with stridor (hot potato voice)

What is the issue?

Causes, Occurence

Epiglottitis is inflammation of the epiglottis and/or the supraglottic tissues surrounding the epiglottis, including the aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula.

Haemophilus influenza B , use of the HiB vaccine has reduced the incidence of epiglottitis

0.3 cases per 100,000

Epiglottitis

Normal

Croup is an infectious illness of the respiratory system involving the voice box and vocal cords.A harsh crowing sound ("stridor") during inhaling can be heard when the child's air passage becomes abnormally narrowed

• It is usually caused by many different viruses, including those responsible for the common cold and influenza.

• Occasionally, it is caused by a bacterial infection.

• Croup can result in serious breathing difficulties in children. It is more common in babies over 6 months of age and young children, and it occurs more often in boys than girls.

• It tends to occur more often in the winter months when the weather is colder.

Croup

Croup/EpiglottitisTreatment?

• The least amount possible.• Keep them calm.• If LOC decreases or breathing is

ineffective BVM!!!• BVM can help stent the airway open.• Child’s own ventilations can worsen the

condition due to their own negative pressure on inspiration collapsing the airway further.

Swelling from Croup

PPV

PPVPPV will help open that obstruction even in a child in complete respiratory arrest.

RSVRespiratory Syncytial Virus

• It is the major cause of lower respiratory tract infection and hospital visits during infancy and childhood.

• There is no vaccine. • Treatment is limited to supportive care, including

oxygen.• In temperate climates there is an annual epidemic

during the winter months• In the United States, 60% of infants are infected during

their first RSV season, and nearly all children will have been infected with the virus by 2–3 years of age, 2–3% will develop bronchiolitis, necessitating hospitalization

RSV Treatment

Treating respiratory syncytial virus bronchiolitis "remains a good example of therapeutic nihilism—nothing works except oxygen".

Adrenaline, bronchodilators, steroids, and ribavirin confer "no real benefit“

Treatment is supportive care only, with fluids and oxygen until the illness runs its course

Albuterol may be used in an attempt to relieve any bronchospasm if present. Increased airflow, humidified and delivered via nasal cannula, may be supplied in order to reduce the effort required for respiration.

Recent studies with hypertonic saline have shown that the "use of nebulized 3% HS is a safe, inexpensive, and effective treatment for infants hospitalized with moderately severe viral bronchiolitis" where "respiratory syncytial virus (RSV) accounts for the majority of viral bronchiolitis cases"

^ Jenny Handforth, Mike Sharland, Jon S Friedland. Editorial: Prevention of respiratory syncytial virus infection in infants. BMJ 2004;328:1026–1027 (1 May), doi:10.1136/bmj.328.7447.1026