Mod V: Pediatric Airway management

Question 1

_{Pediatric Airway management}

Airway management can prove particularly challenging in the pediatric patient due to:

Answer 1

Physiological and anatomical issues

Question 2

_{Physiologic Issues}

Physiologic issues that make Airway management particularly challenging in the pediatric patient include:

Answer 2

Low FRC

High O2 consumption

High “alveolar/FRC” ratio

These all lead to RAPID DESATURATION!!!

Question 3

_{Physiologic Issues}

Why are infants and neonates dependent on HR for CO?

Answer 3

Noncompliant ventricles

Question 4

_{Physiologic Issues}

Which CV complication would Hypoxia lead to very quickly in peds?

Answer 4

CV collapse

Hypoxia => Bradycarddia => CV collapse

Question 5

_{Physiologic Issues}

Why is Airway patency “HIGHEST PRIORITY” in peds vs. adults?

Answer 5

Time from apnea to CV collapse is much shorter in peds vs. adults

Question 6

_{Physiologic Issues}

What dose of Atropine is often administered during induction in peds?

Answer 6

Atropine

Induction dose: 0.02 mg/kg

Question 7

_{Physiologic Issues}

Why is Atropine (0.02 mg/kg) often administered during induction in peds?

Answer 7

To preempt Bradycardia

Remember infants and neonates are dependent on HR for CO due to noncompliant ventricles

Also Hypoxia => Bradycarddia => CV collapse

Question 8

_{Pediatric Airway Equipment}

Preparation for airway management must be complete. What does it include?

Answer 8

Appropriate sized equipment…

must be immediately available

^{(Laryngoscopes, oral airways, LMA’s, ETT)}

Several airways of each type…

should be prepared to allow quick adjustment should this be required

Question 9

_{Pediatric Airway Equipment - Laryngoscopes}

How do peds Laryngoscopes handle differ from adult’s ones?

Answer 9

Narrower

Less cumbersome

Lighter weight

More natural feel with smaller blade

You can put the smaller blade on the big handle, just feels akward!!!

Question 10

_{Pediatric Airway Equipment - Laryngoscopes}

Blades Assortment sizes:

Answer 10

0, 1, 2

Question 11

_{Pediatric Airway Equipment - Laryngoscopes}

Blades Styles:

Answer 11

MAC vs. Miller

Wis-Hippel or Robertshaw (Wide flange)

^{Engages tongue left - Facilitates ET passage}

Question 12

_{Pediatric Airway Equipment - Laryngoscopes}

Curved Laryngoscope blade types. During laryngoscopy, the tip or beak of the blade is compressed into the angle formed by the base of the tongue and the epiglottis, indirectly raising the epiglottis:

Answer 12

Macintosh or Mac Blade

Question 13

_{Pediatric Airway Equipment - Laryngoscopes}

Straight laryngoscope blade is traditionally recommended for intubation in infants, due to the large size and flexibility of the infant epiglottis, since it allow to lift the epiglottis directly:

Answer 13

Miller Blade

Question 14

_{Pediatric Airway Equipment - Laryngoscopes}

Straight blade with a wider flange more like the Mac blade; this blade is also known as:

Answer 14

Wis Hipple Blades

Question 15

_{Pediatric Airway Equipment - Laryngoscopes}

Blade designed for neonatal and infant use, this blade features a wide flange and a gentle shallow curvature of the blade to lift the epiglottis indirectly in a similar way to the Macintosh blades

Answer 15

Robertshaw Blade

Question 16

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Mac Blade size for Ages 1-2 y/o

Answer 16

MAC 1

^{(9 cm)}

Question 17

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Mac Blade for Ages 3-5 y/o

Answer 17

MAC 2

^(11cm)

Question 18

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Miller Blade size for Neonate/Infant:

Answer 18

Miller 0

Question 19

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Miller Blade size for Ages 1-2 y/o:

Answer 19

Miller 1

Question 20

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Miller Blade size for Ages 2-6 y/o:

Answer 20

Miller 2

Question 21

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Wis-Hippel Blade size for Ages 1-2 y/o:

Answer 21

Wis-Hipple 1

Question 22

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Wis-Hippel Blade size for Ages 3-4 y/o:

Answer 22

Wis-Hipple 1.5

Question 23

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Mac Blade size for Ages > 8 y/o

Answer 23

MAC 3

Question 24

_{Pediatric Airway Equipment - Laryngoscopes}

Recommended Miller Blade size for Ages > 8 y/o:

Answer 24

Miller 2-3

Question 25

_{Pediatric Airway Equipment - Laryngoscopes} Recommended blade (curve vs straight) for \< 2 y/o

Answer 25

**Straight** _{(Recommended for < 2 y/o)}

Question 26

_{Pediatric Airway Equipment - Laryngoscopes} Recommended blade (curve vs straight) for \> **5 y/o**

Answer 26

**Curved** _{(Recommended for > 5 y/o)}

Question 27

_{Pediatric Airway Equipment - Endotracheal Tubes} ET tube size for **Preterm (\< 1000g):**

Answer 27

**2.5 mm**

Question 28

_{Pediatric Airway Equipment - Endotracheal Tubes} ET tube size for Preterm (\> 1000 gm)

Answer 28

**3.0 mm**

Question 29

_{Pediatric Airway Equipment - Endotracheal Tubes} ET tube size for _Neonate to 3 mos_.:

Answer 29

**3.0 mm**

Question 30

_{Pediatric Airway Equipment - Endotracheal Tubes} ET tube size for _3-9 mos_.:

Answer 30

**3.5 mm**

Question 31

_{Pediatric Airway Equipment - Endotracheal Tubes} ET tube size for _9-18 mos_.:

Answer 31

**4.0 mm**

Question 32

_{Pediatric Airway Equipment - Endotracheal Tubes} Formula for calculating ET tube size for ≥ 2 y/o:

Answer 32

**(Age/4) + 4** = xx mm ET tube

Question 33

_{Pediatric Airway Equipment - Endotracheal Tubes} Diameter of which body part can be used to estimate ET tube size in peds?

Answer 33

**Pinky** diameter

Question 34

_{Pediatric Airway Equipment - Endotracheal Tubes} What test can we perform to confirm that we have the appropriate ETT size?

Answer 34

**Airway Leak Test** Test airway pressure at which gas audibly escapes around ETT _Appropriate ETT size_ must allow for leak **@ 15-25 cm H20** pressure The leak test will minimize the likelihood that an excessively large tube has been inserted. Correct tube size and appropriate cuff inflation is confirmed by easy passage into the larynx and the development of a gas leak at 15 to 25 cm H2O pressure.

Question 35

_{Pediatric Airway Equipment - Endotracheal Tubes} What conclusion could you draw regarding your ET tube size, if it takes \> 25 cm H20 of pressure to get a leak on the Airway Leak Test?

Answer 35

**ETT too large** This could lead to Tracheal edema Which could lead to postextubation croup No leak indicates an oversized tube or overinflated cuff that should be replaced or deflated to prevent postoperative edema.

Question 36

_{Pediatric Airway Equipment - Endotracheal Tubes} What conclusion could you draw regarding your ET tube size, if it takes \< 15 cm H20 of pressure to get a leak on the Airway Leak Test?

Answer 36

**ETT too small** ETT too small or you need more air in your cuff A leak that large could lead to: **Inadequate ventilation** **Aspiration** **OR pollution** *An excessive leak may preclude adequate ventilation and contaminate the operating room with anesthetic gases*

Question 37

_{Pediatric Airway Equipment - Endotracheal Tubes} What other size ET tubes should you Always have available in the addition to the appropriate or calculated size?

Answer 37

**Half size smaller** ETT and **Half size larger** ETT

Question 38

_{Pediatric Airway Equipment - Endotracheal Tubes} What's the appropriate ETT depth for peds \< 1 year of age?

Answer 38

\< 4 kg = 6 + Wt (kg) \> 4 kg = 10 cm @ lip

Question 39

_{Pediatric Airway Equipment - Endotracheal Tubes} How is the appropriate ETT depth calculate for peds \> 1 year of age?

Answer 39

12 + (Age ÷ 2) or 3X’s ID

Question 40

_{Pediatric Airway Equipment - Endotracheal Tubes} What's the appropriate 4.0 ETT depth for peds \> 1 year of age?

Answer 40

3X’s ID = 3 x 4.0 = 12cm 4.0 ETT depth = 12 cm

Question 41

_{Pediatric Airway Equipment - Endotracheal Tubes} How can you ensure that the tip of the ETT tube is just proximal to the carina?

Answer 41

You want the **Double black line** on the ETT tube just past the **Vocal Cords** When double black line on the uncuffed ET tube passes through cords, tip is proximal to carina

Question 42

_{Pediatric Airway Equipment - Endotracheal Tubes} What are the steps of the most precise method to estimate appropriate ET tube depth?

Answer 42

**Intubate** the pt **Advance ETT** until _BS lost_ over _L axilla (R mainstem)_ Note length at carina & pull back while bagging the pt until you hear bilateral BS to mid trachea Then, you can say that the tube is as deep as possible while maintaining bilateral BS

Question 43

_{Pediatric Airway Equipment - Endotracheal Tubes} What's the normal **distance** between the vocal cords & the carina?

Answer 43

**4-5 cm**

Question 44

_{Pediatric Airway Equipment - Endotracheal Tubes} Where should the inflated cuff be palpated on the patient if properly positionned?

Answer 44

**Suprasternal notch**

Question 45

_{Pediatric Airway Equipment - Endotracheal Tubes} What distance should be added to _Nasal RAE tube_ for appropriate depth?

Answer 45

**2-3 cm**

Question 46

_{Pediatric Airway Equipment - Face Masks} What are the different types of Face masks?

Answer 46

Bubble Masks Rendell-Baker-Soucek Masks

Question 47

_{Pediatric Airway Equipment - Face Masks} What are some characteristics of Bubble Masks?

Answer 47

↑ Dead-space Pneumatic cushion Easier to maintain airtight fit Effective seal for PPV

Question 48

_{Pediatric Airway Equipment - Face Masks} What are some characteristics of Rendell-Baker-Soucek Masks?

Answer 48

**↓Dead-space** Low profile Difficult to maintain airtight fit

Question 49

_{Pediatric Airway Equipment - Face Masks} Correct Fit of the Rendell-Baker-Soucek Masks?

Answer 49

**Apex** = bridge of _nose_ **Base** = crease of lower _lip/chip_

Question 50

_{Pediatric Airway Equipment - Face Masks} Which face is apppropriate if you are concerned about increased deadspace?

Answer 50

**Rendell-Baker-Soucek Masks** ↓Dead-space

Question 51

_{Pediatric Airway Equipment - Face Masks} Which face mask is easier to maintain airtight fit?

Answer 51

Bubble Masks

Question 52

_{Pediatric Airway Equipment - Face Masks} Which face mask provides effective seal for PPV?

Answer 52

**Bubble Masks** It's nearly impossible to generate PPV with Rendell-Baker-Soucek Masks This is why they have fallen hugely out of favor and have been replaced by Bubble Masks

Question 53

_{Pediatric Airway - Mask Ventilation} Why is Mask Ventilation challenging in the child \< 4 y/o?

Answer 53

Smaller **face** Large **tongue** Set up for **Upper airway obstruction**

Question 54

_{Pediatric Airway - Mask Ventilation} Which actions or condition may facilitate Upper airway obstruction?

Answer 54

**Provider's fingers** may compress soft tissues of the neck Excessive **neck extension** **Laryngomalacia** = supraglottic tracheal collapse with inspiration

Question 55

_{Pediatric Airway - Mask Ventilation} Supraglottic tracheal collapse with **inspiration** is also known as:

Answer 55

**Laryngomalacia** _{This is a congenital softening of the tissues of the larynx (voice box) above the vocal cords. This is the most common cause of noisy breathing in infancy. The laryngeal structure is malformed and floppy, causing the tissues to fall over the airway opening and partially block it​}

Question 56

_{Pediatric Airway - Mask Ventilation} What's the proper placement of face mask (FM) and fingers for effective Mask ventilation technique?

Answer 56

Place **FM** over _nose/mouth_ **Forefinger/thumb** over _FM_ **Middle-finger** on _boney prominence of mandible_

Question 57

_{Pediatric Airway - Mask Ventilation} How is Manual Airway opening performed for mask ventilation?

Answer 57

**Chin lift** **Jaw thrust** **Apply CPAP** (not to exceed _15 cmH2O_)

Question 58

_{Pediatric Airway - Mask Ventilation} PPV or CPAP for mask ventilation is not to exceed which pressure value?

Answer 58

**15 cmH2O**

Question 59

_{Pediatric Airway - Mask Ventilation} Failed manual opening of the airway for mask ventilation should be replaced with which alternatives?

Answer 59

**Oral airway** **Nasal airway**

Question 60

_{Pediatric Airway - Nasal Airways} As with adults, Nasal Airways are better tolerated in awake pts. Why are Nasal Airways not frequently used w/ peds?

Answer 60

Most children have **Adenoidal hypertrophy** from _2-6 y/o_ Could disrupt that tissue and cause **Bleeding** Which could lead to a **laryngospasm** and _other problem_s Small internal diameter of nasal airways could **↑ work of breathing** according to _Poiseuille’s law_

Question 61

_{Pediatric Airway - Nasal Airways} How to properly size a nasal airway?

Answer 61

**Flange** at _tip of nose_ **Distal tip** at _angle of mandible_

Question 62

_{Pediatric Airway - Oral Airways} T/F: Oral airways are poorly tolerated in awake or slightly anesthetized pts.

Answer 62

**True**

Question 63

_{Pediatric Airway - Oral Airways} How is Proper sizing of oral airway performed?

Answer 63

**Flange** at _lip_ **Distal tip** at **angle of mandible**

Question 64

_{Pediatric Airway - Oral Airways} Proper sizing of oral airway is important. An oral airway that is Too small will:

Answer 64

**Push tongue back**

Question 65

_{Pediatric Airway - Oral Airways} Proper sizing of oral airway is important. An oral airway that is Too large will:

Answer 65

**Obstruct laryngeal outlet**

Question 66

_{Pediatric Airway - Oral Airways} Oral Airways size for Preterm:

Answer 66

**[000/00**] 3.5- 4.5 cm

Question 67

_{Pediatric Airway - Oral Airways} Oral Airways size for \< 3mos:

Answer 67

**[0]** 5.5 cm

Question 68

_{Pediatric Airway - Oral Airways} Oral Airways size for **3-12mos**:

Answer 68

**[1]** 6.0 cm

Question 69

_{Pediatric Airway - Oral Airways} Oral Airways size for **1-5 y/o**:

Answer 69

**[2]** 7.0 cm

Question 70

_{Pediatric Airway - Oral Airways} Oral Airways size for **\> 5 y/o**:

Answer 70

**[3]** 8.0 cm

Question 71

_{Pediatric Airway - Laryngeal Mask} LMA considerations in peds:

Answer 71

**More rigid** in peds Suitable for **short procedures** Low ventilatory **resistance** Use if _conventional mask difficult_ _Not recommended_ for **PPV** _Contraindicated_ in pt at risk for **gastric aspiration**