Mod IV: Pediatric Airway

Question 1

_{Pediatric Airway}

There are some unique traits to the pediatric airway if compared to adult airway. What could make DL challenging and Mask ventilation difficult in peds?

Answer 1

Large tongue

(Peds have a disproportionally large tongue)

Question 2

_{Pediatric Airway}

Why is Mask ventilation difficult with peds?

Answer 2

The disproportionally large tongue tends to want to Obstruct the airway

You also may or may not obstruct the airway accidently by applying excessive submandibular pressure, and not really focusing on keeping your hands or your fingers on the mandible

Question 3

_{Pediatric Airway}

Where is the glottic opening located in peds?

Answer 3

More cephalad & anterior appearing

Question 4

_{Pediatric Airway}

What is the vertebral level of the glottic opening in Premature Infant/Neonate

Answer 4

C3

Question 5

_{Pediatric Airway}

What is the vertebral level of the glottic opening in Full Term Infants?

Answer 5

C4

Question 6

_{Pediatric Airway}

Where is the Narrowest portion of the peds airway?

Answer 6

Cricoid ring

This is different from the adult airway

Question 7

_{Pediatric Airway}

Why would 1mm edema in peds have greater effect than adult?

Answer 7

Trachea shorter/smaller diameter

Question 8

_{Pediatric Airway}

Where is the narrowest portion in the adult airway?

Answer 8

Glottic opening

Question 9

_{Pediatric Airway}

1mm edema in peds has greater effect than adult because the peds trachea is shorter/smaller in diameter compared to the adult trachea. Which physical law is responsible for this?

Answer 9

Poiseuille’s law

Which states the “resistance to air flow is directly proportional to the radius to the 4th degree”

Question 10

_{Pediatric Airway}

How does pediatric larynx differ from adult’s larynx in shape?

Answer 10

Peds Larynx is funnel shaped vs. Adult latynx is cylindrical

Question 11

_{Relative Effects of Airway Edema}

In a normal infant how much space do you have across the trachea?

Answer 11

~ 4mm

Question 12

_{Relative Effects of Airway Edema}

In a normal adult, how much space do you have across the trachea?

Answer 12

~ 8mm

Question 13

_{Relative Effects of Airway Edema}

In an adult

1mm of edema increases the resistance by ___ times

and decreases the cross sectional area by ___ %

Answer 13

3 times

44 %

Question 14

_{Relative Effects of Airway Edema}

In pediatrics

1mm of edema increases the resistance by ___ times

and decreases the cross sectinal area by ___ %

Answer 14

16 times

75%

This is why tracheal edema in peds is significant as far as the obstruction of air flow

Question 15

_{Pediatric Airway}

In the peds airway, why is the Epiglottis Difficult to fix with DL?

Answer 15

Weird shape!!!

Narrow, long, U (omega)-shaped, floppier & protruding

Question 16

_{Pediatric Airway}

In the peds airway, which blade aids in lifting the Epiglottis out of the way during DL?

Answer 16

Straight blade

You can acually catch the epiglottis and move it, instead of passively lifting it with a Mac blade

Question 17

_{Pediatric Airway}

Why is nasal/blind “intubation” difficult in peds?

Answer 17

Vocal cords are in a diagonal position,

not perpendicular

Question 18

_{Pediatric vs. Adult Airway}

See picture

Answer 18

_Note:

Large tongue

Shape of the larynx

Glottic opening (more anterior in peds)

Question 19

_{Pediatric Airway}

Why are pediatric pts “Obligate nose breathers”?

Answer 19

Weak pharyngeal muscles

As a result they can easily obstruct because of secretions or choanal atresia (if born with that)

Question 20

_{Pediatric Airway}

What is choanal atresia?

Answer 20

Congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development

Question 21

_{Pediatric Airway}

Why should you always have LMA/OA/ET readily available with peds?

Answer 21

Complete airway obstruction is possible and must be anticicpated

Place LMA/OA/ET to reestablish airway patency

Question 22

_{Pediatric Airway}

Why is positioning the patient for intubation, including putting them in the sniffing position sometimes difficult?

Answer 22

Peds have Large heads

It’s best to apply something under the infant shoulders to bring their chest up, so you can really bring them into that true sniffing position for intubation

Question 23

_{ORAL BREATHING}

What percentage of infants with a PCA of 31-32 weeks are capable of oral breathing if the nasal passages are obstructed?

Answer 23

Only about 10%

Question 24

_{ORAL BREATHING}

What percentage of infants with a PCA of 35-36 weeks are capable of oral breathing if the nasal passages are obstructed?

Answer 24

About 30%

Question 25

_{ORAL BREATHING} What percentage of infants with a PCA of full term infants (PCA of 40 weeks) are capable of oral breathing if the nasal passages are obstructed?

Answer 25

About 40% (less than half)

Question 26

_{ORAL BREATHING} By what age do almost all infants are capable of oral breathing if the nasal passages are obstructed?

Answer 26

By about **5-months** of age

Question 27

_{Pulmonary Function} Why can't peds maintain negative intrathoracic pressure?

Answer 27

They have a **Compliant chest** and a **Pliable rib cage**

Question 28

_{Pulmonary Function} What's a negative outcome of peds attempting to maintain negative intrathoracic pressure

Answer 28

It diminishes attempts to increase ventilation

Question 29

_{Pulmonary Function} Why are peds at high risk for **premature alveolar collapse**?

Answer 29

High **closing volumes** which fall within lower range of normal VT Leads to **premature alveolar collapse**

Question 30

_{Pulmonary Function} From a diaphragmatic standpoint, why are peds at risk for quicker respiratory failure?

Answer 30

Diaphragm deficient in **Type I, slow-twitch, fatigue resistant muscle fibers** This results in earlier fatigue of muscles fibers involved in supporting breathing These muscle fibers are necessary for performing repetitive work a/w respiration These muscle fibers are essential for sustained increase respiratory effort As a result, peds fatigue earlier than adults This places them at risk for quicker respiratory failure

Question 31

_{Muscle Composition} At what age do "Type I slow-twitching, high oxidative muscle fibers" become as predominant in peds as in adults?

Answer 31

At aorund **2 yrs of age**

Question 32

_{Pulmonary Function} Regarding Lung Development, when do Earliest alveolar/capillary network appear?

Answer 32

24-26 weeks gestation

Question 33

_{Pulmonary Function} Which protein is responsible for preventing alveolar collapse during expiration? How?

Answer 33

**Surfactant** It lowers alveoli surface tension, improving pulmonary compliance and allowing the lungs to inflate more easily This helps eliminate some of the work-of-breathing It also prevents the alveoli from collapsing at the end of expiration The reduction in alveoli surface tension is required for the maintenance of alveoli surface area on which respiration is dependent

Question 34

_{Pulmonary Function} At what gestational age does Surfactant first appear?

Answer 34

At **20 weeks** gestation

Question 35

_{Pulmonary Function} At what gestational age does Surfactant production accelerate?

Answer 35

At **30-34 weeks** gestation

Question 36

_{Pulmonary Function} At what age is full maturation of the lungs completed?

Answer 36

At 8 y/o

Question 37

_{Pulmonary Function} Why do peds have increased RR (35-40/min) & alveolar ventilation?

Answer 37

They have a **higher metabolic demand** Tissues need more O2 b/c peds are constantly growing until they reach their adult state

Question 38

_{Pulmonary Function} Why would peds desaturate quicker than adults?

Answer 38

**Lower FRC** compared to adults 25-30 ml/kg in infants vs 40 ml/kg in adults **Higher minute ventilation** to **FRC ratio** **5:1** in infants vs. **1.5:1** in adults

Question 39

_{Pulmonary Function} Why are peds subject to more rapid inhalational induction?

Answer 39

**Higher minute ventilation** to **FRC ratio** 5:1 in infants vs. 1.5:1 in adults

Question 40

_{Pulmonary Function} T/F: VT & deadspace are equivalent to adults

Answer 40

True

Question 41

_{Pulmonary Function} What's the average VT?

Answer 41

**5-7** mL/kg/min

Question 42

_{Pulmonary Function} What's the average Deadspace?

Answer 42

**2-2.5** mL/kg/min

Question 43

_{Pulmonary Function} Apnea characterized by "cessation of breathing \>15 secs", Quite common in premature infants (\<55 weeks PCA), Rare in full term neonates is also known as:

Answer 43

**Central apnea**

Question 44

_{Pulmonary Function} Why is Central apnea Quite common in premature infants (\<55 weeks PCA)

Answer 44

Immature CNS

Question 45

_{Pulmonary Function} Why is it important to know if a pt was a premature infant with underdevelopped lungs or if they are less than 55 weeks PCA?

Answer 45

B/c if they are less than 55 weeks PCA, and even if it is a typical outpatient procedure, **they will usually spend the night for obeservation**, just so we can monitor their breathing

Question 46

_{Pulmonary Function} The type of apnea characterized by breathing with 10-15 sec periods of apnea

Answer 46

**Periodic apnea** Occurs in 80% of full term infants & 95% of preterm infants

Question 47

_{Pulmonary Function} Periodic apnea occurs in what percentage of full term infants?

Answer 47

80%

Question 48

_{Pulmonary Function} Periodic apnea occurs in what percentage of preterm infants?

Answer 48

95%

Question 49

_{Pulmonary Function} What's a benefit of **Hypoxia** during apneic episodes?

Answer 49

Hypoxia initially **stimulates ↑ in ventilation**

Question 50

_{Pulmonary Function} Outline of neonate Mean Pulmonary Function values as compared to an adult

Answer 50

See table

Question 51

_{Pulmonary Function} Treatment of larygospasm in peds

Answer 51

Sux + Atropine PPV via bag mask You do not necessarily need to intubate