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ANESTHESIA-Pediatrics Airway Syndromes

ANESTHESIA-Pediatrics Airway Syndromes

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Published by hollyu

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Published by: hollyu on Aug 28, 2010
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07/22/2013

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P
EDIATRIC
A
IRWAY
S
YNDROMES
 
A
NESTHETIC
C
ONSIDERATIONS
 
1.
 
Considerations for the Pediatric (cooperation, physiology, pharmacokinetics)2.
 
Potential Difficult Intubation/Ventilationa.
 
Surgical airway vs intubation attemptb.
 
Awake vs asleepc.
 
Spontaneous ventilation vs paralyzed3.
 
Potential Aspiration Risk & Co-existing Obstructive Sleep Apnea4.
 
Potential for Unstable or Immobile Cervical Spine5.
 
Coexisting multiple congenital anomalies particularly CHD
A
NESTHETIC
G
OALS
 
1.
 
Establisha.
 
Aspiration Risk b.
 
Cervical Spine Stabilityc.
 
Presence of OSA & Associated Anomalies2.
 
Minimize anesthetic related post operative respiratory depression
K
EY
A
NESTHETIC
I
SSUES
 
1.
 
Simple maneuvers may relieve airway obstruction
 – 
prone positioning, pulling tongueforward (suture in tongue, oro/nasopharyngeal airway, LMA)2.
 
Pre-operative assessment of associated organ system involvement (CHD, renal)3.
 
Don’t forget option of intraop tracheostomy if postop airway management is going to be
very difficult4.
 
Awareness of the dynamic status of the airway as patient grows or the disease progresses5.
 
Specific Syndromesa.
 
Cleft lip and palatei.
 
associated with Pierre Robin, CHDii.
 
L sided cleft may be a difficult laryngoscopyb.
 
Pierre-Robin syndromei.
 
Micrognathia, cleft palate, glossoptosisii.
 
CHDc.
 
Beckwith-Wiedemann syndromei.
 
Macrosomia, macroglossiaii.
 
Hypoglycemiaiii.
 
Associated with omphaloceleiv.
 
Likely easy laryngoscopy but difficult BMV
H
ISTORY
 
 
Previous anesthetics and experience with AW management (but kids grow!)
 
Airway
 
Details of congenital syndrome
 
Evidence of acute on chronic AW obstruction (infection, foreign body)
 
Noisy breathing/ stridor
 
Snoring
 
Symptoms of OSA
 
Complete perinatal Hx
 
Complications of Pregnancy
 
History of acute/ chronic airway obstruction
 
 
Aspiration symptoms/ reflux
 
Symptoms of cervical spine involvement
 
Occipital/ neck/ upper extremity pain or paresthesias
 
Limited range of motion
 
Coexisting syndrome abnormalities e.g. cardiac (cyanosis, murmur)
 
P
HYSICAL
 
 
Signs of distress including agitation, retractions, cyanosis, anxiety, weak or absent cry, orstridor
 
Anatomical AW abnormalities including:
 
Oral cavity (macroglossia, microstomia [small mouth], distortion [hemangioma,glottic webs])
 
Anterior mandibular space (micrognathia, anterior larynx)
 
Maxilla (hypoplasia, nasal obstruction/mouth breathing)
 
TMJ (restriction to opening [fixed vs. secondary], reduced translocation [inability to jut jaw forward])
 
Vertebral column (restricted movement, instability)
 
Resp: pattern and rate, wheeze (aspiration?), stridor, positional dyspnea
 
CVS: pulses, cap refill, murmur, pulm HTN (OSA)
 
Signs of associated congenital pathology or previous surgery
I
NVESTIGATIONS
 
 
C-spine XR, PA & lateral (mobility, instability)
 
Echo (if congenital heart disease)
O
PTIMIZATION
 
 
EMLA
 
ENT consult/ backup
 
Caution with Premedication with co-existing OSA
 
Aspiration prophylaxis
 
Antisialagogue
 
SBE Prophylaxis if CHD
A
NESTHETIC
O
PTIONS
 
 
Maintenance of spontaneous ventilation is paramount in those patients with anticipateddifficult ventilation/ intubation
 – 
 
avoid muscle relaxants
 
 
Awake instrumentation of the AW is virtually impossible in the pediatric patient
 
Recognition of 
conflicts
of difficult A/W plus: pediatric patient, full stomach, raised ICP,CHD with shunt & pulmonary hypertension, malignant hyperthermia
A
NESTHETIC
S
ETUP
 
 
Experienced help
 
Difficult Airway Cart
 
LMAs
oral and nasal A/W’s available to facilitate PPV
 
 
Selection of preferred blades (curved may be better with macroglossia)
 
Multiple ETT sizes
 
Surgeon/ Tracheostomy/ Percutaneous cricothyroidotomy equipment
A
NESTHESIA
M
ANAGEMENT
 
 
Inhalational
 – 
Sevo but recognized relatively quick offset
 
TIVA
 – 
Propofol/remi infusion +/- bolus
 
 
Consider preop lidocaine nebulization to facilitate FOB intubation under sedation, or tofacilitate placement of oral airway under light plane of anesthesia
B
ACKGROUND
 
 
Pediatric vs Adult Airway - 5 Major Anatomical Differences
 
Large Tongue
 
In proportion to rest of oral cavity, and so more easily obstructs airway
 
Position of Larynx:
 
Infant: (C3-4); adult (C4-5); premature baby C3
 
Epiglottis narrower/stiffer and angled away from the axis of trachea
 
Vocal Cords have lower attachment anteriorly
 
Whereas in adults they rest perpendicular to trachea; this difference cansometimes lead to difficulty with intubation of infant
 
Subglottic area (cricoid cartilage) is narrowest part of airway
 
Whereas in an adult is the rima glottides
S
PECIFIC
S
YNDROMES
 
 
Cleft lip & palate:
 
Most common congenital A/W abnormality (lip 1/1000 livebirths, palate 1/2500)
 
Cardiac abnormalities in 20%
 
Possibly chronic aspiration
 
Associated with many other craniofacial disorders (over150), commonly Pierre Robin syndrome (also Mohr, Shpritzen, 4P)
 
Technical specifics:
 
Isolated cleft lip usually
doesn’t present AW difficulties
 
 
Obstruction by tongue is usually overcome with oral AW
 
Left-sided cleft palate may interfere with normal positioning of laryngoscopeblade
 
Pierre Robin syndrome:
 
Micrognathia, glossoptosis (abnormal downward or back placementof the tongue), respiratory obstruction +/- cleft palate and CHD
 
Pulm HTN, cor pulmonale, or pulm edema secondary to chronic A/Wobstruction
 
Technical specifics:
 
May obstruct A/W when supine
 
Oral, nasal A/W and prone positioning may facilitate ventilation
 
Fiberoptic laryngoscopy often required
 
Older patients may be easier to intubate as mandible grows
 
Craniofacial dysostosis
:
 
Craniosynostosis (premature closure of cranial sutures)
 
Midface hypoplasia (normal-sized mandible with prognathia) +/-hydrocephalus, hypertelorism, proptosis, cervical fusion, trachealrings
 
Associated with Apert, Crouzon (towering skull, beaked nose) and
Pfeiffer’s syndromes
 
 
May have obstructive apnea severe enough to require tracheostomy
 
May have inc ICP
 
May require massive transfusion if multiple sutures (large bore IV, blood products)

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