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Management of Airway and Breathing

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					   Management of
Airway and Breathing
    RHSC Edinburgh
              Objectives
• To understand the differences between
  children and adults
• To understand that airway and breathing
  should be considered together
• To recognise the compromised airway
• To recognise inadequate breathing
• To be able to support compromised airway
  and breathing as required
What are the differences between the
  paediatric and the adult airway?
              Anatomy
• Smaller airway
• Large tongue
• Floppy epiglottis
• Funnel shape - cricoid narrowest part of
  larynx (up to ~ 10yrs)
• Larynx is anterior and high in the neck
• Positioning may be affected by relatively
  large occiput in infants
• Babies < 6 months are obligate nasal
  breathers: blocked nose = blocked airway

• Ventilation is mainly diaphragmatic – if
  diaphragm movement is impeded tidal
  volume is reduced (eg full stomach)

• Trachea & bronchi are smaller – a minimal
  obstruction makes a big difference to flow
• Why do children desaturate faster than
  adults?
        Supply and demand!

• Ventilatory reserve is less

• O2 consumption is higher because
  metabolic rate is higher
  – 6-8ml/kg/min in children
  – 3-4ml/kg/min in adults
   Signs of airway compromise
• See-saw                          Lung          Diaphragm           Expiration


  respirations
     • Diaphragm
       flattens
     • Abdo contents         Air
                                          Lung           Diaphragm
                                                                     Normal
                                                                     inspiration
       pushed down
     • Abdo rises
     • Chest “sucked in”
     • Paradoxical                                                    See-saw
                                                         Diaphragm
                           Air        Lung                            respirations
    Signs of airway compromise

•   Stridor
•   Drooling
•   Increased work of breathing
•   Reduced or absent air entry
•   Low / falling SaO2
Signs of respiratory compromise
• Increased work of breathing
    • Increased respiratory rate
    • Nasal flaring
    • Intercostal, subcostal, suprasternal and sternal
      recession
    • Head-bobbing
    • Prolonged expiration +/- wheeze
    • Grunting
Signs of respiratory compromise
• Poor chest excursion and air entry
• Cyanosis/low SaO2
• Hypoxaemia and or hypercapnia with
  acidosis on blood gas
• Tachycardia then bradycardia
• Reduced conscious level
• Problem
  detected –
  NOW WHAT!?!
• Back to basics
    •   Assess ABC
    •   Get help
    •   High flow O2
    •   Positioning – sit up if alert/able
    •   DO NOT distress the child
    •   Treatment for specific problem (eg wheeze)
• Consider IV Access (likely to be needed)

• Investigations as appropriate
     •   Blood tests
     •   Cultures
     •   Gases
     •   CXR
                       Asthma
• 9% of children - most common disease of
  childhood

• Death rates for all ages – 50% at home

  – 2.1 / 1,000,000 children < 5 years

  – 3.7 / 1,000,000 children 5-14 years

  – 2 / 10,000 of those hospitalized
        Management of asthma
•   Nebulised Salbutamol & Atrovent
•   Steroids
•   IV Salbutamol
•   IV Aminophylline
•   IV Magnesium sulphate
•   Mechanical ventilation
•   Volatile anaesthetic agents
•   Heliox
•   ECMO
        Management of asthma

•   Escalation of medical management
•   Consultation with PICU early
•   Protocols
•   Aim is to avoid intubation if at all possible
       • Difficult to ventilate
       • Risk of iatrogenic pneumothorax,
         pneumomediastinum
       • Mucous plugging and atelectasis
       • Nosocomial infection
            • Intubation may turn this




Into this
Obtunded with compromised
    airway or breathing
• Get help
• High flow O2
• Simple airway manoeuvres
• Suction (remember nasal suction in
  infants)
• Consider adjuncts – OPA, NPA
• Ventilatory support with bag-valve-
  mask if required
              Airway adjuncts
• Oropharygeal airway       • Nasopharyngeal airway
  (OPA)                       (NPA)
  – In infants and young      – Use appropriate sized
    children insert right       ETT cut to length
    way up with tongue        (tip of nose to tragus of ear)
    depressor
    Bag-valve-mask ventilation
• Well-fitting face mask
• Correct head position
   – Neutral for infants
   – “Sniffing” for younger
     children
• Fingers on bone
• One or two person
  technique
• Watch chest wall movement
• Consider OGT/NGT to
  decompress stomach
• Does this child need intubation?
     Indications for intubation
• Decision to intubate can be difficult

• Threshold for intubation is lower if patient
  is to be transferred

• Aim to optimise condition prior to transfer
      Indications for intubation
• Deteriorating airway
     • recession, “see-saw” breathing, stridor
     • Potential airway obstruction eg trauma, burns


• Respiratory distress
     •   Tachypnoea
     •   Chest wall recession
     •   Hypoxaemia: SaO2 < 94%, or PaO2 < 8 kPa
     •   Hypercapnia with acidosis: PaCO2 > 6 or < 3.5 kPa
     •   Exhaustion
     •   Apnoeas
     •   Respiratory arrest
      Indications for intubation
• Shock
          –   HR > 180 or < 80 (< 5yrs), > 160 or < 60 (> 5yrs)
          –   absent peripheral pulses
          –   cold peripheries
          –   capillary refill > 2 sec
          –   systolic blood pressure < 70 + (age in years x 2)
     • Not responding to fluids > 60mls/kg
     • Requiring inotropes


• Deteriorating level of consciousness
     • GCS 8 or less
     • Responding to Pain on AVPU


• Recurrent seizures
• Intubation should be undertaken by an
  appropriately skilled person
        Preparing for intubation
• Assessment of the patient
       • Assume full stomach – IV induction should be
         rapid sequence induction (RSI)
•   Equipment
•   Drugs
•   Personnel
•   A plan for failure
           Assessing the patient
• History
     • current illness
           – Airway obstruction? Consider gas induction
           – Shock? Induction agents vasodilate – consider drug/dose
           – Head injury? Avoid raised ICP in response to laryngoscopy
     • previous intubation details
     • ?difficult airway eg Pierre Robin
• Examination
     •   head - shape / size
     •   mouth - size / opening
     •   teeth - size / integrity
     •   jaw - size / receding
     •   tongue - size
     •   neck - mobility / Cx spine injury / swelling / masses
                  Equipment
•   Laryngoscope x 2 and appropriate blades
•   Appropriate size ET tubes
•   Airway adjuncts
•   Suction
•   Stylet & or bougie
•   Magills forceps
•   Monitoring - including ETCO2 if available
•   Scissors and tape
•   KY jelly
                      Drugs
• Sedating agent
  – If unstable reduce dose or consider Ketamine
• Muscle relaxant
  – Suxamethonium unless CI for RSI
• Sedation and opiate infusions for maintenance
• Emergency drugs
  – Atropine
  – Adrenaline
  – Consider infusion of inotrope if haemodynamically
    unstable
• See retrieval website for dose calculations
           www.paedsretrieval.co.uk
    Rapid Sequence Induction algorithm
• Preparation:       equipment / drugs / patient / personnel
                     IV access patent, checked
                     monitoring on, working
                     aspirate nasogastric tube
                     suction
•   Pre-oxygenation
•   Administer anaesthetic agent
•   Cricoid pressure
•   Administer suxamethonium
•   Intubation
•   Position check
•   Tracheal tube fixation
•   Position check
            Failed intubation drill
• Maintenance of oxygenation is the priority

•   Call for HELP
•   Do not make persistent attempts at intubation
•   Do not give repeated doses of suxamethonium
•   Maintain a patent airway
•   Bag and mask ventilate to maintain oxygenation
•   Continue cricoid pressure unless it is impeding ventilation
•   Left side and head down unless this impedes ventilation
       Key points for intubation
• Oxygenation is always the priority

• Never lose control of the airway “can’t intubate, can’t
  ventilate”
• Bag valve mask ventilation is the default position of
  safety
• An adequately trained team is required / ask for help
• Adequate patient assessment and equipment
  preparation
• Plan for a failed intubation
               After the tube is in….
• Maintenance infusions
    – Sedative, opiate +/- relaxant
•   Monitor ETCO2
•   NGT if not already inserted
•   CXR to confirm position
•   If problems, think DOPES
       •   D    displacement
       •   O    obstruction
       •   P    pneumothorax
       •   E    equipment
       •   S    stomach
                 Summary
• Children are not small adults
• Anatomical and physiological differences make
  them more at risk of respiratory problems
• Assessment, O2 and simple supportive
  measures initially
• Call for help early
• If required intubation should be undertaken by
  appropriately trained personnel
• Adequate preparation is needed

				
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posted:12/29/2012
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