how to manage air way in pediatrics ...

1. PEDIATRIC AIRWAY
TECHNIQUE
DR ABDUL RUB
MEM PGY2
MISSION HOSPITAL

2. Devices
 Nasal cannula
 Simple O2 Mask
 Non- rebreathing mask
Bag valve mask ventilation
 Intubation
 OTHERS…..

3. Nasal Cannula
 FiO2 0.22-0.40
 Prongs should not completely occlude the nares-multiple
sizes available
 **Ensure pt nares are patent**
 Use with bubble humidifier

4. Nasal Cannula Sizes
Size Max Flow
Premature (< term) 2 LPM
Neonate (>1400 g) 2 LPM
Infant (newborn, term) 2 LPM
Intermediate Infant
(3-12 mo)
2 LPM
Pediatric (>1yr) 3 LPM

5. Simple O2 Mask
• FiO2 0.35-0.50
• ****Minimum 5 LPM O2 flow!!!!******
• Can’t really titrate O2
• Pt can’t eat/ drink
• Use with bubble humidifier
• Gently press on metal bar to conform to pt’s face. Do
NOT pinch!

7. Partial Non- Rebreathing Mask
 FiO2 0.60-0.90 (depending on mask fit)
 Minimum 5 LPM for infant/child, 10 LPM for teens. Match
flow to need
 Reservoir bag and one-way valve limit amount of RA
inspired and ↓ dilution of FiO2
 Gently press on metal bar to conform to pt’s face. Do
NOT pinch!

9. Estimating FiO2
O2 Flow rate FiO2 O2 Flow rate FiO2 O2 Flow rate FiO2
Nasal cannula Oxygen mask Mask with reservoir
1 0.24 5-6 0.4 6 0.6
2 0.28 6-7 0.5 7 0.7
3 0.32 7-8 0.6 8 0.8
4 0.36 9 0.80+
5 0.4 10 0.80+
6 0.44

10. Oropharyngeal Airway
SIZE
PROPER
POSITION
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

11. Choosing correct OPA
 Place OPA against side of face. With flange
at the corner of the mouth the tip should
reach angle of the jaw
 Too small: will not adequately displace tongue
 Too large: may obstruct larynx and/ or interfere
with mask fit if BVM required

12. Nasopharyngeal Airways
 Soft plastic pre-made or shortened ETT
 Provides unobstructed path for airflow between
nares and pharynx
 Can use in conscious/ semi-conscious pt
 Small internal diameter so must be evaluated
frequently and suctioned prn to maintain
patency

13. Nasopharyngeal Airway
•Distance from nares to angle of mandible approximates the proper length
•Nasopharyngeal airway available in 12F to 36F sizes
•Shortened endotracheal tube may be used in infants or small children
•Avoid placement in cases of hypertrophied adenoids - bleeding and
trauma Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt

15. Appropriate Size is Key
Correct size Incorrect size
(Atlas of Airway

16. OXYGEN TENT
CLEAR PLASTIC SHELL THAT COVERS THE PATIENTS
UPPER BODY
PROVIDES MORE THAN 50% OF O2
NOT RELIABLE
ACESSES TO CHILD LIMITED
CAN NOT BE USED IN EMERGENCY SITUATION

17. Breathing
Bag-Mask Ventilation

18. **Multiple Mask sizes available so choose the correct one**

19. Infants: Want
exterior ear
canal to be
anterior to the
shoulder
shoulder roll
works best for
positioning
infants and
small children

20. Bag-Mask Ventilation
 Indicated when the pt’s spontaneous breathing
effort is inadequate despite patent airway
 Can provide adequate oxygenation and
ventilation until definitive airway control is
obtained
 Can be as effective as ventilation through ETT

21. Bagging
Units
 3 sizes:
Age Volume (ml)
Infant 500
Child 1000
Adolescent 2000

22. Testing the bagging unit
 Check all components before use to ensure
proper function. Ideally as part of your daily
safety checks.
 Occlude pt outlet and outflow, squeeze bag
ensure no tears/leaks
 Ensure connection to wall O2 and adequate flow
 Proper size mask with cuff inflated

23. Bag-Mask Ventilation
Sellick
Maneuver
Breathing

25. Bagging
1. Position pt: sniffing position
2. Open airway and seal mask to face using E-C
technique. You may need OPA.
3. Squeeze bag with other hand to deliver tidal
volume and produce chest rise. Careful to not
over-ventilate!

26. 2 person BMV
 One person uses both hands to open airway and
maintain tight mask-to-face seal
 2nd person bags

27. Monitor effectiveness of
Ventilation
 Visible chest rise with each breath
 SpO2
 ETCO2
 HR
 BP
 Pt responsiveness
 Air entry on auscultation

28. If ventilation is not
effective…
 Reposition pt. Reposition airway. OPA.
 Verify proper mask size and placement
 Suction airway
 Check O2 source and flow
 Check bag and mask for function/leaks
 Treat gastric inflation

29. If these don’t work…
 Pt may require more advanced interventions to
establish a patent airway
CPAP
Intubation

30. Sniffing Position
Patient flat on operating ttaabbllee,, tthhee oorraall ((oo)),,
pphhaarryynnggeeaall ((PP)),, aanndd ttrraacchheeaall ((TT)) aaxxiiss ppaassss tthhrroouugghh
tthhrreeee ddiivveerrggeenntt ppllaanneess
AA bbllaannkkeett ppllaacceedd uunnddeerr tthhee oocccciippuutt aalliiggnnss tthhee
pphhaarryynnggeeaall ((PP)) aanndd ttrraacchheeaall ((TT)) aaxxeess
EExxtteennssiioonn ooff tthhee aattllaannttoo--oocccciippiittaall jjooiinntt
aalliiggnnss tthhee oorraall ((OO)),, pphhaarryynnggeeaall ((PP)),, aanndd
ttrraacchheeaall ((TT)) aaxxeess
Image from: http://depts.Washington.edu/pccm/Pediatric%20Airway
%20management.ppt

31. Preparing for Intubation
 Appropriate ETT for >1 yo: (age/4) + 4
Term infant: 3.0-3.5 ID
6 mo: 3.5-4.0 ID
1 yo: 4.0-4.5 ID
 Cuffed ETT’s for pt’s > 8 yo
 If you anticipate need for high PEEP or PIP may want to use
cuffed ETT with <8 yo. Use ½ size smaller ETT.
 Remember SOAPME

32. Tracheal Tube Sizes
Insufflation Pressure ?
Muscle Relaxants?
Age (Size (mm ID Insertion length
(Alveolar ridge(
Preterm 1000g
Preterm 1000-2500g
2.5
3.0
cm 6-9
Neonate-6 Month 3.0-3.5 cm 10
Month – 1 Yr 6 3.5-4.0 cm 11
Yrs 1-2 4.0-5.0 cm 12
Beyond 2 Yrs age (yrs(/4 + 4 age (yrs(/2 + 12

33. Equipment: Blade and
Tube Size
Age Blade/Size
Infant Miller 1
2 years old Miller 2
12 years old Miller/Mac 3
“Switch to a 2 at 2”

34. Intubation -
Techniques
 Always enter from the right corner
 Tongue control is critical
 Lift the epiglottis with the Miller
 Slide the Mac into the vallecula
 Can lift the epiglottis if needed

35. Laryngoscopy Technique

36. Curved blade technique
a) Open the patient's mouth with the
right hand, .
b) Grasp the laryngoscope in the left
hand
c) Spread the patient's lips, and
insert the blade between the
teeth, being careful not to break a
tooth.
d) Pass the blade to the right of the
tongue, and advance the blade
into the hypopharynx, pushing
the tongue to the left.
e) Lift the laryngoscope upward and
forward, without changing the
angle of the blade, to expose the
vocal cords.

37. Curved blade technique
f) take the endotracheal tube, made of flexible plastic, in the
right hand and starts inserting it through the mouth
opening.
g) The tube is inserted through the cords to the point that the
cuff rests just below the cords
h) Finally, the cuff is inflated to provide a minimal leak when
the bag is squeezed
Using a stethoscope , listens for breathing sounds to ensure
correct placement of the tube

38. Straight blade technique
Follow the steps outlined for curved blade technique, but
advance the blade down the hypopharynx, and lift the
epiglottis with the tip of the blade to expose the vocal
cords.
The tip of the laryngoscope blade fits below the epiglottis,
which is no longer visible with the blade in position.

39. Intubation -
Trouble-shooting
 Can’t see the cords
 Look for landmarks
 Control the tongue
 BURP maneuver if epiglottis seen
 Another attempt needed (limit number)
 Reposition
 Change something (blade, tube)
 Avoid hypoxia

40. Confirmation of ETT Placement
 Seeing tube go through cords
 Clinical Confirmation
Water vapor seen inside tube
O2 Saturation
Chest rise
Equal breath sounds
No sounds over epigastrium
 CO2 Detection / Esophageal Detector Devices
 Chest X-ray
NO single technique is 100% reliable

41. Rescue Devices
 LMAs (laryngeal mask airway)
 I-LMAs (intubating LMA)
 Combitube
 Bougie
 Pick one or two and practice
 Need to be comfortable before crisis

42. LMA
 Used in any age
 Easy to place
 Few complications
 Contraindications:
 Gag reflex
 FBs
 Airway obstruction
 High ventilation pressure
 Does not secure airway

43. Laryngeal Masks
Indications:
When
endotracheal
intubation is not
necessary or it’s
difficult
Contraindications:
• Non-fasted
patients
• Morbidly
obese
patients
• Obstructive
or abnormal
lesions
of the
oropharynx
Air entry is confirmed by
listening for air entry into the
lungs with a stethoscope

44. The cuff of the mask is deflated before insertion
and lubricated.
1.The patient is sedated or fully anaesthetized if
conscious, and their neck is extended &mouth
opened widely.
2.The apex of the mask, with its open end pointing
downwards toward the tongue, is pushed
backwards towards the uvula.

45. 3.The cuff follows the natural bend of the
oropharynx, and its long walls come to rest
over the piriform fossa.
4.Once placed, the cuff around the mask is
inflated with air to create a tight seal.

46. Laryngeal Mask
Higher success rate
Does NOT protect from
aspiration
Difficult to maintain
during transport

47. Advantages vs. Disadvantages
Advantages:
•Allows rapid access
•Does not require laryngoscope
•Relaxants not needed
•Provides airway for spontaneous or
controlled ventilation
•Tolerated at lighter anesthetic planes
Disadvantages:
• Does not fully protect against aspiration
in the non-fasted patient
• Requires re-sterilization

48. LMA Sizing
LLMMAA SSiizzee PPaattiieenntt SSiizzee
11 NNeeoonnaattee // IInnffaannttss << 55 kkgg
11 ½ IInnffaannttss 55--1100 kkgg
22 IInnffaannttss // CChhiillddrreenn 1100--2200 kkgg
22 ½ CChhiillddrreenn 2200--3300 kkgg
33 CChhiillddrreenn//SSmmaallll aadduullttss 3300--5500 kkgg
44 AAdduullttss 5500--7700 kkgg
55 LLaarrggee aadduulltt >>7700 kkgg

50. Combitube
 Two sizes
 Small (4 to 5.5 feet tall)
 Regular (over 5.5 feet
tall)
 Not useful in most kids
 Easy to place
 Contraindications
Gag reflex
 Esophageal disease
 Caustic ingestions
 FBs/Airway obstruction

51. Other Toys
 Lighted stylet
 Flexible fiberoptic
scopes
 Rigid fiberoptic
scopes
 Bullard
 Shikani
 Video
laryngoscopy

52. Rules
“To avoid trouble one must be prepared for trouble”
“Have an IV access & experienced assistant”
“Do what you masters”
“Have definitive plan A, but have plan B & C”

53. Rules
“Use your common sense”
“ Do not continue to do the same thing and expect
different results’’
“Easier comes first”
“Each difficult intubation is a different”

54. THANKS