Pediatric Pearls IPediatric Pearls I

Delon F.P. Brennen MD,MPHDelon F.P. Brennen MD,MPH

Pediatrics / Pediatric Emergency MedicinePediatrics / Pediatric Emergency Medicine

Morehouse School of MedicineMorehouse School of Medicine

ObjectivesObjectives

• Pediatric Airway and Airway Management

• Discuss Airway/Respiratory Emergencies

The Pediatric AirwayThe Pediatric Airway

Anatomy / Physiology Positioning Adjuncts Intubation

IntroductionIntroduction

Almost all pediatric “codes” are of respiratory origin

Internal Data. B.C. Children’s Hospital, Vancouver. 1989.Internal Data. B.C. Children’s Hospital, Vancouver. 1989.

Pediatric Pediatric Cardiopulmonary Cardiopulmonary

ArrestsArrests

Pediatric Pediatric Cardiopulmonary Cardiopulmonary

ArrestsArrests

1° Respiratory

Shock

1° Cardiac

1° Respiratory

Shock

1° Cardiac

10% 10%

80%80%

AnatomyAnatomy

Children are very different than adults !!!Children are very different than adults !!!

Pediatric AirwayPediatric Airway

• Anatomy Issues– Large head that tends to flex the short neck

and obstruct the airway – Disproportionately large tongue – Larynx is more cephalad and anterior – Cricoid cartilage is the narrowest point of the

airway until about age 8 – Shorter trachea leaves less margin for error in

placement of the endotracheal tube

Anatomy :Anatomy :

• NoseNose

• Responsible for 50% of total airway resistance at all ages

• Infants are obligate nasal breathers: blockage of nose = respiratory distress

Anatomy :Anatomy :

• TongueTongue

• Large

• Loss of tone with sleep, sedation, CNS dysfunction

• Frequent cause of upper airway obstruction

Anatomy :Anatomy :• LarynxLarynx

• High position / Cephalad• Infant : C1• 6 months: C3• Adult: C5-C6

• Anterior position

Children Children areare different different

Anatomy : LarynxAnatomy : Larynx

Narrowest point = cricoid cartilage in the child

Anatomy :Anatomy :

• EpiglottisEpiglottis

• Relatively large size in children•• Floppy – not much cartilage

• Omega () -shaped

Physiology: Effect of Physiology: Effect of EdemaEdema

Poiseuille’s lawPoiseuille’s law

If radius isIf radius is halvedhalved, , resistance increasesresistance increases 16-fold16-fold

R =R = 8 n l8 n l rr44

Airway positioning for Airway positioning for children <2yrschildren <2yrs

Airway Airway PositioningPositioning

““Sniffing Position”Sniffing Position”In the child older than 2 yearsIn the child older than 2 years

Airway adjunctsAirway adjuncts

• Nasal airway

• Oral airway

Nasopharyngeal Nasopharyngeal AirwayAirway

ContraindicationsContraindicationsBasilar skull fractureBasilar skull fracture

CSF leakCSF leak

CoagulopathyCoagulopathy

Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusIndications:Indications:• Conscious PatientConscious Patient

• Upper Airway Upper Airway obstruction – prolapse of obstruction – prolapse of tongue and mandibular tongue and mandibular block of tissue into the block of tissue into the posterior pharynxposterior pharynx

Endotracheal tube as nasal Endotracheal tube as nasal airwayairway

Endotracheal tube as nasal Endotracheal tube as nasal airwayairway

A regular ETT can A regular ETT can be cut and used as be cut and used as a nasal airwaya nasal airway

Oral AirwaysOral Airways

Measure: Measure: Lips to Lips to angle of angle of the the mandiblemandible

Never in a conscious patient !!!Never in a conscious patient !!!

Adjuncts: Oral AirwayAdjuncts: Oral Airway

Wrong size: Too LongWrong size: Too Long

Adjuncts: Oral Adjuncts: Oral AirwayAirway

Wrong size: Too ShortWrong size: Too Short

Adjuncts: Oral Adjuncts: Oral AirwayAirway

Correct sizeCorrect size

Signs of Respiratory Distress ?Signs of Respiratory Distress ?

• TachypneaTachypnea• TachycardiaTachycardia• Grunting Grunting • StridorStridor• Head bobbingHead bobbing• FlaringFlaring• Inability to lie downInability to lie down• AgitationAgitation

• RetractionsRetractions• Access musclesAccess muscles• WheezingWheezing• SweatingSweating• Prolonged expirationProlonged expiration• Pulsus paradoxusPulsus paradoxus• ApneaApnea• CyanosisCyanosis

Impending Respiratory Impending Respiratory FailureFailure

• Reduced air entry• Severe work• Central Cyanosis despite O2

• Irregular breathing / apnea• Grunting• Altered Consciousness• Diaphoresis

Intubation: IndicationsIntubation: Indications

• Failure to oxygenate

• Failure to remove CO2

• Increased WOB

• Neuromuscular weakness

• CNS failure

• Cardiovascular failure

IntubationIntubation

• Larynx cephalad and anterior in children

– Practitioner may need to be lower than patient and look up

Laryngoscope Laryngoscope BladesBlades

Macintosh

Miller

Intubation Intubation TechniqueTechnique

Straight Straight Laryngoscope Laryngoscope Blade (Miller) – Blade (Miller) – used to pick up used to pick up the epiglottisthe epiglottis

Better in younger children with a floppy epiglottisBetter in younger children with a floppy epiglottis

Intubation TechniqueIntubation Technique

Better in older children who have a stiff epiglottisBetter in older children who have a stiff epiglottis

Curved Curved Laryngoscope Laryngoscope Blade (Mac) – Blade (Mac) – placed in the placed in the valleculavallecula

IntubationIntubation

AgeAge kgkg ETT ETT Length (lip) Length (lip)

NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12

Technique: Technique: IntubationIntubation

How far does How far does it go in ?it go in ?

Deterioration after Deterioration after IntubationIntubation

Deterioration after Deterioration after IntubationIntubation

• Displaced tube

• Obstructed tube

• Pneumothorax

• Equipment

• Displaced tube

• Obstructed tube

• Pneumothorax

• Equipment

Questions ?Questions ?

Oh, it ain’t over!Oh, it ain’t over!

The TestThe Test

• 6 week old infant comes to the ED with signs of respiratory distress. Which of the following would be consistent with impending respiratory failure?– Bilateral basilar rales– Resp Rate = 45bpm– Audible Grunting– Wheezing at the axillae– Acrocyanosis

Question 2Question 2

• 14 month old comes to the ED with cyanosis, tachypnea, and altered mental status. Which of the following supports the decision to intubate the child’s trachea immediately?– ABG with pH 7.25– Pulse ox of 87% on RA– PaCO2 of 56mmHg– PaO2 of 56mmHg– Clinical assessment of respiratory failure

Question 3Question 3

• Unconscious 15yo brought to the ED because of massive facial trauma and bleeding. He was punched and kicked by 4 girls and is now in respiratory distress. Which is the best method of securing his airway?– Nasopharyngeal airway– Nasotracheal intubation– Oropharyngeal airway– Cricothyroidotomy– Bag-Valve Ventilation– Testicular Implant

Question 4Question 4

• 6 week old brought to the ED. Mother is concerned that her baby “ain’ ackin right”. Which of the following vital signs reflect respiratory distress, failure, and shock?

– RR 60bpm, HR 160bpm, SBP 75mmHg– RR 50bpm, HR 150bpm, SBP 75mmHg– RR 80bpm, HR 180bpm, SBP 60mmHg– RR 45bpm, HR 130bpm, SBP 80mmHg– RR 30bpm, HR 100bpm, SBP 70mmHg

Question 5Question 5

• Which of the following physical findings is seen only in lower airway disease?– Audible grunting– Inspiratory Stridor– Tachypnea– Rales– Cyanosis

Question 6Question 6

• 5 yo with Asthma arrives in A&E in acute distress. Patient has marked tachypnea, subcostal retractions, and diffuse wheezing. Which method of O2 delivery will deliver the highest possible concentration of oxygen?– Nasal cannulae– Face tent– Nonrebreather mask– Venturi mask

Question 7Question 7

• You have just intubated the trachea of a 6 month old. Which of these best demonstrates the correct placement of an endotracheal tube?– Bilateral breath sounds over the chest + abd– Condensation in the tube

– Slight improvement in the O2 saturation

– Assessment of end-tidal CO2

– Chest wall movement

Question 8Question 8

• 3 hours later while receiving mechanical ventilation, the child acutely decompensates. Which of the following would be the least helpful in the management of this child?– Suction the ET– ABG– CXR– Auscultate both lung fields– Evaluate the ventilator

Question 9Question 9

• Infants are more susceptible than adults to respiratory emergencies because of which of the following?– Greater resistance in lower airways– Larger tongue, small mandible, soft epiglottis– More compliant, less stable chest wall– Higher metabolic requirements– All of the above

Question 10Question 10

• 3yo brought to the ED after parents noted coughing while playing. Now have dyspnea and stridor. Which of the following is indicated at this time?– Four hard back blows– Finger sweep of child’s mouth– Nasotracheal intubation– Abdominal thrusts– Nebulized racemic epinephrine

Question 11Question 11

• Pulse oximetry can be accurately used to monitor patients with all of the following except:– Hypoxemia– Carbon monoxide poisoning– Sickle cell disease– Cystic fibrosis– Cyanotic heart disease

Question 12Question 12

• Which of the following clinical conditions is NOT an indication for intubation?– Hypoventilation– Loss of protective airway reflexes– Severe bronchospasm– Metabolic alkalosis– Pulmonary toilet

Question 13Question 13

Is that enough?Is that enough?

Issues?Issues?