Airway and Intubation ✅

Question 1

What is true of the airways in children compared to adults?

Answer 1

There are many anatomical airway differences between infants, children, and adults, and the younger the child, the more pronounced the difference

Question 2

What is the importance of the difference in childrens airways?

Answer 2

It has relevance to emergency care, particularly airway opening manoeuvres, airway adjuncts, and endotracheal intubation

Question 3

Why can life threatening airway obstruction develop rapidly in children?

Answer 3

As the airway is already narrow, and further airway narrowing from any cause increases resistance according to Pouseuille’s law

Question 4

How is Pouseuille’s law applied to airways?

Answer 4

As resistance is inversely proportional to the fourth power of the radius, a small reduction in an already small airway radius will result in a large increase in resistance

Question 5

What can neck flexion or overextension lea to in infants?

Answer 5

Airway obstruction by tracheal compression

Question 6

Why can neck flexion or overextension lead to airway obstruction in infants?

Answer 6

Due to the relatively large head and short neck in infants

Question 7

What else can cause airway obstruction in infants?

Answer 7

The relatively large tongue

Question 8

When in particular can an infants tongue cause airway obstruction?

Answer 8

If there is a reduced level of consciousness

Question 9

What other problem might the tongue cause?

Answer 9

May impede the view at laryngoscopy

Question 10

What manoeuvres are used to open the airway in children?

Answer 10

• Head tilt/chin lift

- Jaw thrust

Question 11

How do airway manoeuvres used in children work?

Answer 11

They apply anterior tension to the hyoid bone and draw the epiglottis away from the posterior pharyngeal wall, opening the pharynx

Question 12

In addition to drawing the epiglottis away from the pharyngeal wall, how else does jaw-thrust improve airway potency?

Answer 12

It pulls the tongue, which may cause airway obstruction, away from the palate and opens the oropharynx

Question 13

What care must be taken when performing airway opening manoeuvres in children?

Answer 13

When positioning the fingers, as the floor of an infants mouth is easily compressible

Question 14

What is it important to do when performing head tilt/chin lift in an infant?

Answer 14

Control the degree of head tilt to avoid airway narrowing due to overextension of the head and neck

Question 15

What head position is preferred when opening the airway in an infant?

Answer 15

Neutral position

Question 16

Why is a neutral position preferred when opening the airway in an infant?

Answer 16

Due to the large head and short neck

Question 17

What head position is used when opening the airway in a child?

Answer 17

The sniffing position

Question 18

When is the head tilt/chin lift manoeuvre contraindicated?

Answer 18

If there is a history of trauma

Question 19

Why is the head tilt/chin lift manoeuvre contraindicated if there is history of trauma?

Answer 19

It may exacerbate cervical spine injury

Question 20

What is the purpose of an oropharyngeal airway, or Guedel airway?

Answer 20

It creates an open channel between the mouth to the posterior pharyngeal wall

Question 21

When are oropharyngeal airways used?

Answer 21

Only in infants and children with reduced level of consciousness

Question 22

Why are oropharyngeal airways only used in infants and children with reduced level of consciousness?

Answer 22

As they may cause choking or vomiting if the gag reflex is present

Question 23

How are oropharyngeal airways sized?

Answer 23

Measuring distance between anterior nares and tragus of ear

Question 24

What is the problem with airway adjuncts that are too small?

Answer 24

May be ineffective

Question 25

What is the problem with airway adjuncts that are too large?

Answer 25

May cause laryngospasm

Question 26

What is often tolerated better than an oropharyngeal airway?

Answer 26

A nasopharyngeal airway

Question 27

What complication may arise from insertion of a nasopharyngeal airway?

Answer 27

Haemorrhage from the vascular nasal mucosa

Question 28

What is the effect of haemorrhage from vascular nasal mucosa caused by nasopharyngeal airway?

Answer 28

Worsens airway obstruction

Question 29

When is a nasopharyngeal airway contraindicated?

Answer 29

Basal skull fracture

Question 30

What is a laryngeal mask airway?

Answer 30

A device for supporting and maintaining the airway without tracheal intubation

Question 31

Where does a laryngeal mask airway sit?

Answer 31

In the hypopharynx, covering the supraglottic structures

Question 32

What is the result of a laryngeal mask airway covering the supraglottic structures?

Answer 32

It allows relaxation of the trachea

Question 33

What is a laryngeal mask airway helpful for in the emergency setting?

Answer 33

Airway obstruction caused by supra-glottic airway abnormalities, or if bag-mask ventilation is not possible

Question 34

What is the limitation of a laryngeal mask airway?

Answer 34

It does not totally protect the airway from aspiration of the stomach contents, and with high pressure ventilation, gastric distention may occur

Question 35

In who might endotracheal intubation be difficult?

Answer 35

Infants

Question 36

What should endotracheal intubation be preceded by?

Answer 36

Induction of anaesthesia (unless child unconscious)

Question 37

What is involved in induction of anaesthesia before endotracheal intubation?

Answer 37

Drugs for sedation and neuromuscular blockade

Question 38

What clues might suggest a child has a difficult airway?

Answer 38

- Presentation with airway obstruction or stridor - Airway swelling or oedema - History of obstructive sleep apnoea - Syndromes with facial malformations - History of previous difficult endotracheal intubation

Question 39

Give 2 causes of airway swelling or oedema

Answer 39

- Burns | - Anaphylaxis

Question 40

Give 3 facial malformations that might indicate a difficult airway

Answer 40

- Short mandible - Ear deformity - Pierre Robin syndrome

Question 41

Who should be present during intubation when a difficult airway is suspected?

Answer 41

Senior anaesthetist and ENT surgeon

Question 42

Describe the epiglottis in infants?

Answer 42

It is horse shoe shaped and relatively large

Question 43

How does the larynx in infants differ to in older children?

Answer 43

In infants it is high anterior, at C2/3 compared to C5/6 in older children

Question 44

What kind of laryngoscope is more commonly used in infants?

Answer 44

Straight blade (Miller blade)

Question 45

Where is the laryngoscope positioned in infants?

Answer 45

Posterior to the epiglottis

Question 46

What is done to the epiglottis when intubating an infant?

Answer 46

The epiglottis is lifted to allow visualisation of the glottis and vocal folds

Question 47

What kind of laryngoscope is used in children and adults?

Answer 47

Curved blade (Macintosh)

Question 48

Where is the laryngoscope positioned in children?

Answer 48

In the vallecula, anterior to the epiglottis

Question 49

What is done to the epiglottis when intubating a child?

Answer 49

It is lifted to visualise the larynx

Question 50

How are endotracheal tubes sized?

Answer 50

By internal diameter in mm

Question 51

What is the narrowest party of the airway until age 12?

Answer 51

The level of the cricoid cartilage

Question 52

What is the relevance of the cricoid cartilage being the narrowest part of the airway until age 12?

Answer 52

An endotracheal tube that passes easily through the vocal cords may still be too large to pass through the cricoid ring

Question 53

What might the consequence be of an endotracheal tube that is too tight at the level of the cricoid?

Answer 53

May damage the mucosa

Question 54

What might result from mucosal damage at the cricoid ring from a ET tube that is too late?

Answer 54

Airway oedema and post-extubation stridor | Rarely, tracheal scaring and stenosis

Question 55

Can ET tubes with cuffs be safely used in infants and young children?

Answer 55

Yes, providing correct tube size is used, tube position verified, and cuff inflation pressure checked and limited

Question 56

What is the result of ET tubes with cuffs now being confirmed to be safe to use in infants and young children?

Answer 56

They are first choice in paediatric critical care, and preferred in children with poor lung compliance or high airway resistance, or when precise ventilation and/or CO2 control is needed

Question 57

When are uncuffed ET tubes used?

Answer 57

In newborn infants