4. Objectives
By the end of this workshop, the learner will:
‐List 5 anatomical differences between a pediatric and adult
airway
‐Describe in your own words at least 3 physiologic factors that
make pediatric patients more susceptible to hypoxemia
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5. Children are NOT small adults!!!
•Major differences between pediatric and adult
airway are:
‐Size
‐Shape
‐Position
•Pediatric airway similar to adult at approx. 8-14
years of age
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6. Pediatric vs. Adult Airway
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7. Pediatric vs. Adult Airway
•Conical larynx
•Narrowest point @ cricoid
ring
•Larger occiput
•Compliant and distensible
large airways
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8. Pediatric vs. Adult Airway
•Larger adenoidal tissues
•Narrower tracheal diameter and shorter tracheal
length
•Narrower larger airways
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9. So what is the relevance?
Larynx more superior and anterior •Shortens thyromental distance
•“Bunching” of the tongue in the
oropharynx
•More acute angle between
tracheal opening & epiglottis
Relatively large tongue •Difficult to move out of the way
Large, floppy epiglottis •Can cause obstruction
•Influences choice of
laryngoscope blade
Conical larynx •Narrowest point is cricoid
•Influences ETT size
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10. So what is the relevance?
Large occiput •Obstructs airway
•Influences patient positioning
Compliant & distensible large •Susceptible to collapse &
airways obstruction
Narrower tracheal diameter, •Alters airway resistance
large airways & shorter tracheal •Can influence WOB
length
Larger adenoidal/tonsillar •Can cause obstruction
tissue •Susceptible to bleeding
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11. Physiologic Differences
•Lower %age of slow twitch muscle fibers
•Preferentially nose-breathers
•Compliant chest wall
•Ribs in a horizontal position
•Flatter diaphragm
•Higher oxygen consumption
•Higher MV:FRC
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12. Physiologic Differences
•Lower %age of slow twitch muscle fibers
•Preferentially nose-breathers
•Compliant chest wall
•Ribs in a horizontal position
•Flatter diaphragm
•Higher oxygen consumption
•Higher MV:FRC
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14. Objectives
By the end of this workshop, the learner will:
‐Decide which O2 delivery device would be most appropriate
given a case-based example
‐Recall at least:
•5 complications associated with the use of airway
adjuncts
•3 complications associated with BVM
‐Practice the placement of airway adjuncts using an airway
task trainer
‐Perform proper bag-valve mask ventilation using an airway
task trainer
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15. Oxygen delivery devices
•Nasal Cannula •Non rebreather mask
•Heated high flow Nasal •Cpap/Bipap
Cannula
•Tent/hoods
•Simple Face mask
•Bag mask
•Venturi mask
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16. •Nasal Cannula
‐ up to 4 lpm (adults 6 lpm)
‐Approximately 24-45% Fio2
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17. Heated High Flow Nasal Cannula
•Uses Optimal heated humidified O2
•Higher flow which causes a
“splinting” effect to the airways
•Reduces WOB
•Flow rates exceed patients
inspiratory flow rate
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18. Heated High Flow Nasal Cannula
•Infant/ Pediatric cannula
‐up to 8 lpm
•Adult Cannula
‐ 10 to 60 lpm
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19. Simple Face Mask
•Flow Rates 6-10 lpm
•Approximately 35%-55%
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20. Venturi Masks
•Allow for a set O2 concentration
•Entrain Room Air
•Liter flow depends on
Set Fio2
•Can deliver up to 100%
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21. Non rebreather mask
•Has a one way valve
•Can deliver close to 100% Fio2
•Liter flow enough to keep the
bag inflated
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22. Bipap/Cpap
•BiPAP- delivers a higher pressure on inspiration,
helping the patient obtain a full breath, and a low
pressure on expiration, allowing the patient to exhale
easily.
•CPAP-delivers a steady pressure of air, which assists the
patient's inspiration (breathing in) and resists expiration
(breathing out).
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29. Oropharyngeal Airway
•Prevents upper airway obstruction
•May be used as a bite block
•May make Bag-valve-mask ventilation more effective
•Should not be used in semi comatose of alert patients
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30. Complications of Oropharyngeal Airways
•Vomiting and aspiration
•Obstruction can occur if the tube is to Large or to small
•Dental damage
•Oral damage
•Laryngospasm
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32. Nasopharyngeal Airway
•May be used to bypass an upper airway obstruction
•Reduce trauma caused by nasotracheal suctioning
•To determine proper size measure from the tip of the
nose to the tragus of the ear plus 2 cm.
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33. Complications of Nasopharyngeal
Airways
•Laryngospasm and coughing (too long)
•Nosebleeds
•Do not use of patients undergoing anticoagulation
therapy.
•Sinus infection
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35. What would you do???
•Intervention
•Why
•Liter flow
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36. •14 y/o male with end-stage CF and recent sinus surgery
is admitted to your service. His blood gas is as followed
pH 7.35 Pco2 60 Pao2 85, HCO3 26
Vital signs O2 sat 88%, RR 30 HR 95 BP 130/90
What would you do?
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37. •16 year old soccer player is admitted to the ICU,
following an acute onset of SOB after a coughing spell.
His recent chest x-ray shows a moderate right sided
pneumothorax. Pt is hemodynamically stable.
•What would you recommend?
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38. •A 6 month old RSV+ is admitted to the ICU with
increase WOB. His vital signs are as followed
HR 180 RR 80 Sat 90
What would you recommend?
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40. Objectives
By the end of this workshop, the learner will:
‐Identify 5 laryngeal anatomic landmarks seen during
laryngoscopy
‐Recall at least 3 indications and 5 complications associated
with orotracheal intubation
‐Choose the appropriate sized ETT and laryngoscopy blade
according to the patient‟s age/weight
‐Decide on an appropriate combination and dosage of
medications required for intubation
‐Carry out the proper sequence of events involved in tracheal
intubation
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41. General Anatomic Overview
Anatomical Pop Quiz
EPIGLOTTIS
ARYEPIGLOTTIC FOLD
CUNEIFORM TUBERCLE
INTERARYTENOID ARCH
CORNICULATE TUBERCLE
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42. Anatomical Pop Quiz
INNERVATION
•Sensation
‐Supraglottic
‐Infraglottic
•Motor
‐Exception
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43. 1st Commandment
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44. 3 Basic Components
•Most difficult airways can be recognized by 3
maneuvers:
‐Examination of the oropharynx
‐Evaluation of the range of motion at the atlanto-occipital
joint
‐Measurement of the mandibular displacement area
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45. Examination of the oropharynx
•With mouth open to the fullest extent and tongue
maximally protruding you can assess:
‐ROM at TMJ
‐Size of tongue
‐Palate (highly arch palate increases difficulty)
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46. Examination of the oropharynx
•Mallampati Classification: degree of airway
difficulty based on ability to visualize
‐Soft palate
‐Faucial pillars
‐Uvula.
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47. Range of motion at the AO joint
•Reduced ROM does not
allow alignment of airway
axes
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48. Mandibular Displacement Area
•Tongue & soft tissues must be displaced and
compressed into this space
•Adequate when distance between the anterior
ramus of the mandible and the hyoid bone is:
‐3 cm (2 finger breadths) in a child
‐1.5 cm in an infant
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49. Indications
•Actual or anticipated compromise in airway
patency, ventilation and/or oxygenation
•Altered mentation/Compromised airway reflexes
•Airway or parenchymal lung disease
•Hemodynamic compromise
•Cardiopulmonary arrest
•Neuromuscular weakness
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50. Equipment/Preparation
•Monitors •ETT, stylet and syringe
•Gloves •Laryngoscope and blade
•Suctioning equipment •Tape/tube holder
‐Test suction •Obtain/verify IV access
‐Ensure within reach •Medications
•CO2 detector
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57. Objectives
By the end of this workshop, the learner will:
‐Assess the need for Rapid Sequence Intubation (RSI) given
case-based examples
‐Summarize the steps for RSI using case-based examples
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58. What is Rapid Sequence Intubation
(RSI)?
•Intubating quickly
•Intubating efficiently
•Intubating without bag-mask ventilation
‐ AVOID bag-mask ventilation
‐ AVOID bag-mask ventilation
‐ AVOID bag-mask ventilation
•BUT… do what you have to do. If you can‟t intubate,
then bag-mask ventilate
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59. When Should I Use RSI?
•Any acute/sudden respiratory decompensation
‐Acute traumas
‐Code Reds
•When risk of aspiration of gastric contents is high
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60. How Do I Perform RSI?
•Prepare
•Preoxygenate
•Premedicate
•Paralyze
•Place ETT
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61. Prepare
•Let the RN and RT know that RSI will be done
‐ That way, they are also ready
‐ Minimize bag-mask ventilation
‐ Cricoid pressure AFTER sedation, although care should be taken to
avoid deforming/moving the airway from view
‐ Once medications are given, give in succession as quickly as possible
•Talk to the patient, if possible
‐ Spontaneously ventilating, even minimally will help prior to induction
•Get in the best position possible
‐ Stand at head of bed & position the patient
‐ Get all equipment ready
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62. Preoxygenate
•Supply 100% oxygen at the highest flow rate
‐Goal is to fill FRC
‐~3-5 minutes, if possible
‐Avoid BMV, if possible
‐This allows for longer apnea time prior to desaturation
‐Patient will still become hypercarbic
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63. Premedicate
•Atropine (0.02 mg/kg IV)
‐Blunt vagal effects of laryngoscopy (especially in infants)
‐Dries secretions
•Lidocaine (1mg/kg IV)
‐Blunts ICP spike from laryngoscopy
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64. Premedication
•Midazolam (0.1-0.2 mg/kg IV/IM/IN)
‐Hemodynamically neutral
•Fentanyl (2-4 mcg/kg IV)
‐Beware of rigid chest when infused quickly
‐Hemodynamically neutral
•Ketamine (1-3 mg/kg IV)
‐Raises BP and HR
‐Useful if hypotensive or with asthma
‐Avoid in head trauma/increased ICP/IOP
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65. Premedicate
•Thiopental (3-5 mg/kg IV)
‐Negative inotrope
‐Decreases CMR & CBF ICP
•Etomidate (0.25 mg/kg IV)
‐Causes adrenal suppression
‐Avoid in septic shock, if possible
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66. Paralyze
• Rocuronium (1.2-1.5 mg/kg IV)
‐ Onset ~60-90 seconds
‐ Duration ~30-45 minutes
OR
• Vecuronium (0.15-0.2 mg/kg IV)
‐ Onset ~3-5 minutes
‐ Duration ~34-60 minutes
OR
• Succinylcholine (1-2 mg/kg IV)
‐ Causes bradycardia with rapid injection in infants
‐ Avoid in burns, crush, neuromuscular disease, renal failure
‐ Causes hyperkalemia due to fasciculations
‐ Onset ~30-60 seconds
‐ Duration ~2-3 minutes
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67. Place ETT
•Use cricoid pressure, if possible
‐Some helpers get overanxious and give too much pressure
‐It may be useful for you to find the best location and then
have someone hold the position
•Place the tube
•Be prepared for difficult airways!!!
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68. REMEMBER:
•Prepare
‐ Good communication
•Preoxygenate
‐ Avoid bag-mask ventilation
•Premedicate
‐ Based on the disease
•Paralyze
‐ Safer to use non-depolarizing if history unknown
•Place ETT
‐ Be prepared for difficult airways
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69. Vignette 1
3 mos. old previously healthy infant presents with
bronchiolitis and requires intubation for impending
respiratory failure. Last fed breast milk 5 hrs ago.
‐What medications are you going to administer?
‐Why?
‐Requires RSI??
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71. Vignette 2
8 year old with ALL who presents with septic shock
and respiratory failure. HR = 150 and BP 80/35.
Drank a coke 3 hrs ago.
‐What medications are you going to administer?
‐Why?
‐What medications would you NOT give?
‐Requires RSI??
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73. Vignette 3
18 year old previously healthy male presents S/P
MVA. He acutely becomes altered with a GCS=7.
His HR is 120 and BP is 120/80.
‐What medications are you going to administer?
‐Why?
‐What medications would you NOT give?
‐Requires RSI??
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74. Premedicate (risk of increased ICP)
•+/-Atropine (0.02 mg/kg IV)
•Lidocaine (1mg/kg IV)
•Thiopental (3-5 mg/kg IV) – if hemodynamically
intact
OR
•Etomidate (0.25 mg/kg IV) – if hypotensive
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76. Objectives
By the end of this workshop, the learner will:
‐Be aware of the institutional protocol for a “Known/Suspected
Critical Airway”
‐List at least 3 complications associated with LMA insertion
‐Choose the appropriate sized LMA according to the patient‟s
weight
‐Practice the placement of LMA „s using an airway task trainer
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77. 1st Commandment
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78. 2nd Commandment
The intubator should always have a
second strategy to provide
oxygenation and ventilation if the
initial airway approach fails.
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79. Remember…
Anticipate
&
Plan
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80. Laryngeal Mask Airway
•Supraglottic device •Indications:
‐ Failed BVM or endotracheal
•Easy to insert intubation
•Low complication rate •Contraindications:
‐ Awake patients or patients
‐Malpositioning
with a gag reflex
‐Increased insertion difficulty ‐ Those requiring high
‐Laryngosapsm pressures to ventilate
‐Bronchospasm
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81. Laryngeal Mask Airway
•It is important to choose the
correct size
‐ Too large will be difficult to
place
‐ Too small will not maitain
an adequate sea
**Combined width of index/middle/ring fingers can be used to estimate size
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Notas do Editor
The major differences btwn a ped and adult airway are size, shape and position IN THE NECK The differences in adult anatomy are particularly marked when compared to infantsThe form and position of the pediatric airway is more like an adults as early as 8yrs of ageSo now well talk about the differences and their clinical implications
Larynx is generally higher (cephalad) and more forward (anterior) in the neck than adults. This is more evident as you appreciate its position in relation to the C spine (GLOTTIS at C3-C4 in newborns, C4-C5 by 2 years of age, C5-C6 in adults) Epiglottis is:longer, floppier and more U-shapedbecomes more adult-like after 3 yoTongue:Relatively large tongue
Larger adenoidal tissues: can contribute to airway obstruction and bleed if traumatized complicating airway managementGreater Raw bc R is inversely proportional to the fourth power of the radius (Poiseuille’s law). Thus even the slightest compromise in radius can cause significant Raw and increased WOB (when flow is laminar, ie at rest, fifth power when turbulent, ie agitation)
Larynx higher and anterior:Shortens thyromental distance “Bunching” of the tongue in the oropharynxGlottis opening at base of the tongue therefore more acute angle btwn tracheal opening and epiglottisEpiglottisDifficult to move out of the way during ETIInfluences laryngoscope blade type TongueCan cause obstruction due to close proximity to soft palateOcciput protuberant thus making the head flex on the C spine and thereby obstructing the airway
Compliant & distensible large airways:Can be susceptible to collapse/obstruction esp with cricoid pressureAdd. sublglottic airway is smaller and more compliant, and supporting cartilage is not well developed compared to adultsUpper airway obstruction can cause tracheal collapse and stridorNarrow/shorter trachea:Greater Raw bc R is inversely proportional to the fourth power of the radius (Poiseuille’s law). Thus even the slightest compromise in radius can cause significant Raw and increased WOB (when flow is laminar, ie at rest, fifth power when turbulent, ie agitation)Larger adenoidal tissues: can contribute to airway obstruction and bleed if traumatized complicating airway managementIMPLICATION: All these things together make the pediatric patient very susceptible to airway obstruction esp when loss of muscle tone/supine position. Additionally, can make visualization of airway difficult and thus ETI is challengingJaw thrust opens both the pharynx and oropharynx. The jaw-thrust maneuver can be a potent arousal stimulus, also improvingrespiratory effort
Lower percentage of type 1 or slow-twitch skeletal muscle fibers in their intercostal muscles and diaphragm. Type 1 muscle fibers are less prone to fatigue. Infants also have lower stores of glycogen and fat in their respiratory muscles. These differences predispose infants to respiratory muscle fatigue.During oral breathing, must use soft palate muscles to maintain an open oral airway.Reduced FRC (40% that of adults in AWAKE infants)Bullets 4 & 5: they hold their respiratory muscles in a slightly inspiratory position.infants have less reserve and are more susceptible to respiratory failure.Additionally, infants have less and immature alveoli
Faster falls in PaO2 during periods of apnea, i.e. for ETI, and/or resp compromise
Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airwayFIRST THINGS FIRST:2 extremes in time:Elective (i.e. MAC) you have time to do full BAAEmergent you don’t have the time, therefore, If emergent quickly perform a basic airway assessment (BAA) BEFORE intubation
Combination predicts adult difficult airway but no ped data
Class 1laryngoscopy yields adequate laryngeal exposure in >99% of adultsClass 3 is 7% adultsNot validated in children and has a high-false positive rate (50%) in identifying difficult pediatric airways
Mandibular space is of importance because the tongue and soft tissues must be displaced and compressed into this spacePotential displacement area is adequate when the distance between the anterior ramus of the mandible and the hyoid bone is…If this space is small it will make laryngoscopy more difficult bc cannot align axes (laryngeal and pharyngeal axes make a more acute angle
i.e. Respiratory failure (or impending)/arrestHead traumaPneumonia, bronchiolitis, etcShock
DEPENDING UPON EMERGENCY of the procedure; consider informing parents/guardians of risks/benefits/alternative. May even delegate someone to do so on your behalf.GET YOUR TEAM READY!Prepare your:TeamYourselfPatientequipmentAnatomy INFLUENCES your choice of equipment
PositioningAdjust the bed, if possible, so pt’s head is level with lower sternumSniffing positionShoulder/head rollAirway patencyAligns all 3 axes to gain a line of vision from the mouth to the glottisIN ALL AGES, axes are correctly aligned for ETI if external auditory canal is anterior to the front edge of the patients shouldersPreoxygenate for at least 3 minSuction: for less than 10 sec and if use soft catheter, suction on the way out
Insert laryngoscope: Hold laryngoscope with left hand, insert blade into right side of pts mouthDisplace tongue to left Position blade tip: Mac vs. MillerLift: Cricoid vs. BURP, 2nd person hold right side of mouth openInsert ETT/Remove stylet: using right hand, insert to predetermined depth, ensure cuff passes through VC/lines on tube at VC, (CAREFUL NOT TO OVER DO IT AS CHILDREN SUSCEPTIBLE TO RIGHT MAINSTEM INTUBATION BC OF SHORTER TRACHEAL LENGTHInflate cuff: A pressure of 20cm H2O is sufficient to provide a seal, but does not compromise mucosal blood flow. Tracheal mucosal blood flow is compromised at 30 cm water pressure, and mucosal blood flow is completely obstructed at pressures of 45 cm water
CO2 detector: color change from purple to yellow. Bag for 6 breathsAuscultation: listen over stomach first then B/L mid axillary lung fields. Esophageal intubation if gurgling sounds heard, BS can be transmitted. Give time for oxygenation to improveConfirm ETT depth and secure with tape/holder, sedation/analgesia, hook up to ventilator
Immediate complications of ETI
Suction should beWorking ANDable to generate at least -80 to -120 but wall-suction able to generate -300mm Hg is preferableIf using flexible suction catheter for nasopharynx. If so, DON’T place it further than approximated
NOT SENSITIVE WITH NON PERFUSING RHYTHM!!!If ped used in adults take out after 6 breaths due to RawIf adults used in peds take out after 6 breaths bc of dead space
Check functionality of laryngoscope/blade apparatus including light bulbChoice of bladeMacIntosh: curved blade is placed in the vallecula, at the base of the tongue, and used to indirectly lift the epiglottis from above.Miller:Infant/child epiglottis is floppy and elusive so straight blade may be safer for child <5yo but curve may also be used if > 2yoblade to be positioned below the epiglottis, which is lifted directly. ****Although this provides an improved view of the larynx, it may stimulate the vagus nerve, which innervates the underside of the epiglottis, resulting in bradycardia.
Full or presumed full stomachRisk of regurgitation and aspiration is high
Bradycardia from airway manipulation and meds can reduce DO2PALS and ACEP recommend atropine for RSI in children <1 yr, 1-5y receiving succinylcholine and for adolescents receiving a second dose of succinylcholineAtropine causes pupillary dilation, Glycopyrrolate an alternative Lido-Suppress autonomic and airway responses to laryngoscopy esp with elevated ICP. However, proof of efficacy in ped. Lit. limited
Benzos blunt endogenous catecholamines therefore can have negative hemodynamic effectsRigid chest with fentanyl >5mcg/kg and high doses can effect hemodynamicsKetamine with increased secretions
Volume load also!!!
Before performing any invasive airway procedure, the provider MUST assess for a potentially difficult airwayFIRST THINGS FIRST:2 extremes in time:Elective (i.e. MAC) you have time to do full BAAEmergent you don’t have the time, therefore, If emergent quickly perform a basic airway assessment (BAA) BEFORE intubation
Easy to insert but dependent on operator experience Malpoitioning/insertion difficulty more common in younger children
Combined width of index/middle/ring fingers can be used to estimate size