Airway Management

Khaled Bshesh, MD
Sr. Consultant Pediatric Intensivist
Head Section, PICU
Hamad Medical Hospital
 THE PEDIATRIC AIRWAY

Children are not little adults !

 PEDIATRIC AIRWAY
Pediatric Airway - Developmental Differences
 PEDIATRIC AIRWAY
Pediatric Airway - Developmental Differences
 PEDIATRIC AIRWAY
Pediatric Airway - Developmental Differences

 Epiglottis
Shape
• Peds: Narrow, fleshy,
angles from trachea
•
• Adult: Broad, Stiffer,
axis parallel to trachea
 PEDIATRIC AIRWAY
Pediatric Airway - Developmental Differences

 Epiglottis Shape
• Peds: Narrow, fleshy,
angles over trachea
•
• Adult: Broad, Stiffer,
axis parallel to trachea
 PEDIATRIC AIRWAY
Pediatric Airway - Developmental Differences

 Vocal Cords angle caudally

 Smaller separation between Hyoid and Thyroid

Cartilages

 Prominent occiput
– Anatomic and Disease Specific Issues that
Predict a Difficult Airway
– THE MOUTH
 Anatomic
• Macroglossia
•
• Micrognathia

• Protruding Upper incisors, missing teeth

• Deeply arched palate, cleft palate

Arthrogryposis - multiplex
• Anatomic
 Macroglossia
 Micrognathia
 Protruding Upper incisors, missing teeth
 Deeply arched palate, cleft palate

• Facial Trauma
 Pediatric AIRWAY
Difficult Airway Signs and Symptoms – the Pharynx
• Trauma
• Bleeding, Burns, Hematoma, Caustic Ingestion
• Infections
• Peritonsillar abscess
• Retropharyngeal Abscess
• Epiglottitis
• Oropharyngeal Edema

• Foreign Body
 AIRWAY Management
Factors That Predispose Children to Respiratory Failure

• I. Thoracic Cage:
 More compliant chest wall
 Decreased intercostal mm mass
 Early fatigue of diaphragm

• II. Differences in CO2 response curve:

 requires higher CO2 levels for infants to increase MV

compared to older children and adults

 Physiology: Effect of Subglottic Edema
Poiseuille’s law 8 mm airway
4 mm airway 1 mm edema
1 mm edema

R= 8 n l
 r4

Resistance increases 16X Resistance increases 3X

X-Sect Area dec 75% X-Sect Area dec 44%

 AIRWAY Management
Factors That Predispose Children to Respiratory Failure

 VII. Decreased support of Distal Airways compared

to adults

• Altered FRC to CC relationship (CC > FRC)

• Distal airways collapse on expiration and are more

difficult to open w subsequent breath

 Closing Capacity = RV + Closing Volume
PHOTO 22

Closing Volume

Closing Volume – point at which dependent airways close during

forced exhalation
 PEDIATRIC AIRWAY
Conditions Causing Convergence of Closing Capacity and FRC
 Elevation of Closing Capacity
• Infancy
• Bronchiolitis / Asthma
• BPD
• Cystic Fibrosis
 Reduction of FRC
• Infancy
• Supine Position
• Pulmonary Edema
• ARDS, Pneumonia
 PEDIATRIC AIRWAY

 Respiratory Failure Predisposition in

Children

• Inefficient Mechanics - Increase WOB

• Insufficient Reserve - Fatigue

 PEDIATRIC AIRWAY
Reasons to Secure the Airway

Respiratory Distress and Fatigue – do not need a blood gas

to figure this out
 AIRWAY Management
Patient Evaluation
 Hx difficult tracheal intubation, Drug Reactions -
especially Sux or muscle relaxants
 Hx of airway trauma, burns, collagen vascular
Disease, or TMJ problems or diseases with small
mouth / jaw

 Inspect mouth, OPEN mouth – how many fingers?

 Can you see the uvula?
 Distance from mandibular symphysis to hyoid bone
 Inspect Neck
 Mobility, tracheal deviation, thick or muscular
PEDIATRIC AIRWAY
Mallampati Visualization Scale
 Hey - this Kid is Sick

 Let’s Get the Tube in

 Get out the Drugs and

Go

 BUT Wait …..

 PEDIATRIC AIRWAY
Emergency Oral Tracheal Intubation - Equipment
• PREPARE, PREPARE, PREPARE, PREPARE
• Suction, Suction, Suction – REAL SUCTION
• Oral airway
• ET Tubes
• Blades with lights that work
• Stylet
• Non-self Inflating Bag and Mask
• Folded Towel for older children
• Anesthetic agents and muscle relaxants
 PEDIATRIC AIRWAY
Emergency Oral Tracheal Intubation - Equipment

• It is OK to use an oral airway, there is no shame with its use !

Oropharyngeal & Nasopharyngeal Airways
• PREPARE, PREPARE, PREPARE, PREPARE
• Suction, Suction, Suction – REAL SUCTION
• Oral airway
• ET Tubes
• Stylets
• Blades with lights that work
• Non-self Inflating Bag and Mask
• Folded Towel for older children
• Anesthetic agents and muscle relaxants
 Intubation - Tube Sizes
• Age kg ETT Length (lip)
• Newborn 3.5 3.5 9
• 3 mos 6.0 3.5 10
• 1 yr 10 4.0 11
• 2 yrs 12 4.5 12

Children > 2 years:

ETT size: Age/4 + 4
ETT depth (lip): Age/2 + 12
Endotracheal Tube Stylets
 PEDIATRIC AIRWAY
Emergency Oral Tracheal Intubation - Equipment
• PREPARE, PREPARE, PREPARE, PREPARE
• Suction, Suction, Suction – REAL SUCTION
• Oral airway
• ET Tubes
• Stylets
• Blades with lights that work
• Non-self Inflating Bag and Mask
• Folded Towel for older children
• Anesthetic agents and muscle relaxants
Laryngoscope Blades
 PEDIATRIC AIRWAY
Emergency Oral Tracheal Intubation - Equipment
• PREPARE, PREPARE, PREPARE, PREPARE
• Suction, Suction, Suction – REAL SUCTION
• Oral airway
• ET Tubes
• Stylets
• Blades with lights that work
• Non-self Inflating Bag/Mask - Positioning
• Folded Towel for older children
• Anesthetic agents and muscle relaxants
Pediatric Airway Positioning
Mask Airway Maintenance

Correct

Incorrect
Pediatric Airway Positioning

WRONG
 Pediatric Airway
Intubation of Patient with Respiratory Distress

• Expect intubation to be difficult until proven

otherwise
• Patient will not tolerate even short periods of
apnea or hypoxia
• Patient in extremis may require less anesthesia for
intubation compared to healthy patient
 PEDIATRIC AIRWAY
Rapid Sequence Intubation

 Preoxygenate (no positive pressure)

 Equipment Preparation

 Induction with anesthetic agent (thiopental, etomidate)

 Sellick Maneuver as consciousness is lost – another
person to perform this – assign someone
 Muscle relaxant
• Sux 1-2 mg/kg + atropine if <5yrs (priming)
• Vec 0.3 mg/kg (priming dose/issue)

 Intubate trachea, inflate balloon if appropriate

 Release cricoid pressure
 AIRWAY EMERGENCIES
The Myriad of Anesthetic Choices

 Routine Emergency
• Etomidate – 0.3 mg/kg IV
• Ketamine – 1 – 2 mg/kg IV or IM
• Narcotic + Benzodiazepines
• Barbiturates (Thiopental) – 3 – 5 mg/kg IV
• Propofol
 Selected Situations
• Hypovolemia
 Ketamine or Etomidate, maybe Fentanyl
• Hypovolemia + Possible Elevated ICP
 Etomidate
• Asthma
 Ketamine
 AIRWAY Management
Muscle Relaxants
 Indications:
• Facilitate smooth tracheal intubation
• Ventilator - patient synchrony
• Reduce barotrauma
 Contraindications:
• Inability to maintain or cannulate airway
 Types:
• Depolarizers - Sux
• Non-depolarizers – most all the others
 Mechanisms of Action
 PEDIATRIC AIRWAY
Unexpected Difficult Airway – expect the worst

• Anticipate !!!
• Mask Ventilate
• Place Oral Airway
• Call for Help
• Place LMA - will not allow high pressure
ventilation
• Bronchoscopy and Surgical Solutions
ThanK You