7/24/2019 intubacion app
1/31
(+)Marianne Gausche-Hill, MD, FACEP, FAAP
Professor of Clinical Medicine, David Geffen School
of Medicine at UCLA; Vice Chair and Chief of the
Division of Pediatric Emergency Medicine, Director
Pediatric Emergency Medicine and EMS Fellowships
Harbor-UCLA Medical Center, Department of
Emergency Medicine, Torrance, California; Chair,
2014 Advanced Pediatric Emergency Medicine
Assembly
Pediatric Airway Management Update
The emergency physician can be challenged with GU
emergencies in pediatrics as they are not seen routinely.
What is normal for an infant, child, and adolescent?
What are some tips and tricks for examination? Whattesting is imperative and do you need a consultant and, if
so, who? What are the most common and life-
threatening types of emergencies?
Review the most common and life threatening
GU emergencies by age category.
Discuss tips and tricks for the assessment andexamination.
Describe the assessment and testing needed
including consultant support.
Monday, March 17, 2014MO-01
8:00 AM- 8:30 AM
(+)No significant financial relationships to disclose
March 17-20, 2014
New York, NY
Advanced Pediatric
Emergency Medicine Assembly
7/24/2019 intubacion app
2/31
Pediatric Airway Management
Update
Marianne Gausche-Hill, MD, FACEP, FAAP
Professor of Clinical Medicine and Pediatrics,
David Geffen School of Medicine at UCLA
Vice Chair and Chief of the Division of Pediatric Emergency Medicine
Director, EMS and Pediatric Emergency Medicine Fellowships
Harbor-UCLA Medical Center, Department of Emergency Medicine
Disclosures
None
7/24/2019 intubacion app
3/31
Objectives
At the end of this session, you will be able to:
Describe clinical scenarios and the variety of airway
management approaches available.
Review current literature for cuffed and uncuffed
tubes, as well as a variety of different maneuvers to
better visualize the pediatric airway and high flow
nasal cannula during intubation.
Discuss the use of video laryngoscopy and its
potential impact on the visualization of the difficult
airway.
Whats New?
Cricoid pressure not recommended
Emphasis on bag-mask ventilation
Cuffed ET tubes preferred
Atropine in RSI algorithm to prevent bradycardia
is controversial/unlikely prevents
High flow nasal cannula to prevent hypoxiaduring apneic period of RSI this is in!
Less etomidate more ketamine in RSI
Difficult airway video laryngoscopy and new
extraglottic devices
7/24/2019 intubacion app
4/31
Case: 9 month-old boy
9 month-old boy brought in by paramedics
with a history of fever presents with
seizure at home
On arrival, patient has stopped seizing,
also has stopped breathing, and oxygen
saturation is dropping 90% - 86%- 80% -
75%
What do you do now?
Where to Begin?
With the basics!
Move to more advanced procedures as needed
Standardize approach
Have contingency plan
Dont be afraid to call for airway experts
7/24/2019 intubacion app
5/31
Airway Management Process
Position the head
Open the airway If no air movement consider FB maneuvers/removal
Consider airway adjuncts to keep airway open
Oxygen if breathing and risk for hypoxia
Suction if secretions
Bag-mask ventilation if apnea or concern forhypoventilation If no chest rise consider FB maneuvers/removal
ETI [with RSI] high flow nasal cannula during apneic period
Difficult airway algorithm (e.g., Video laryngoscopy,extraglottic devices or surgical airway)
Reassess quickly after each intervention
Position the head and open airway
Midline
Avoid excessive
flexion or extension
Towel under
shoulders or bump
under head toachieve position
Jaw thrust VERY
useful in children in
relieving obstruction
7/24/2019 intubacion app
6/31
Airway adjuncts
Oropharyngeal airway (OP)
May need in unconsciouspatient to keep tongue fromoccluding posterior pharynx
Cannot use in patients with anintact gag reflex
Nasopharyngeal airway (NP)
Use in a semi conscious patientto keep the airway open
Excellent for use in overdose
patients or seizure patients
Bag Mask Ventilation
Steps:
Size face mask
Choose bag [Adult,
Pediatric, Infant/Small
Child, Neonatal]
Attach bag to oxygen
EC-Clamp
Control rate and
volume delivered
7/24/2019 intubacion app
7/31
Bag Mask Ventilation
BAG SIZE
Adult 800-1000 mL
Pediatric 450-500 mL
Small Child 290-400 mL
Neonatal
80-120 mL
Watch Out! Bag could be
too small
Bag Mask Ventilation
EC- Clamp
C holds mask
to face
E pulls chin
into mask
makes a clamp
3 fingers on the
jaw line
Doing BMV is as EC (easy) as 1-2-3
7/24/2019 intubacion app
8/31
Bag Mask Ventilation
Hand placement:
EC clamp
Infants - avoid
pressure on
submental area
Only 1 finger
may fit on jaw
line
Bag Mask Ventilation
Too much cricoidpressure may leadto airway obstruction
If no chest rise withBMV lightencricoid pressure
AHA 2010Guidelines de-emphasize use ofcricoid pressure
7/24/2019 intubacion app
9/31
Bag Mask Ventilation
Say Squeeze (just until chest rise initiated) thensay release, release
Control rate and
volume
Give only amount
of air needed to
get chest to rise
Bag Mask Ventilation
Maximum ventilation rate:
Neonates - 40/min
Infants - 30/min
Children - 20/min
Slower rates are best too hard and toofast will cause gastric distension
7/24/2019 intubacion app
10/31
Endotracheal Intubation (ETI)
Preparation is key
Equipment and staff
Consider RSI as a
number of studies
have shown reduction
in complications with
its use
Have a contingency
plan if ETI fails
Endotracheal Intubation (ETI)
Equipment:
Suction
Oxygen
ET tube
Stylet (1 cm from
end of tube)
Laryngoscope withappropriate blade
Pediatric Magill
forceps
CO2 detector
7/24/2019 intubacion app
11/31
Calculation of ETT size - preemies
Weight (kg) Tube size
(mm)
Depth of tube
(cm)
1 kg 2.5 mm 7 cm
2 3.0 8
3 3.0 - 3.5 9
Memorize this or put on a card no good rule
Calculation of ET tube size
Charts based on weight or length
Measurement from a length-basedresuscitation tape (Broselow Tape)
Greater than 1 year of age cancalculate tube size:
Based on age: (Age/4) + 4 Other methods:
Width of the child's little finger nail
Size of nare
7/24/2019 intubacion app
12/31
Ballpark ETT size
Premature infant (2.5-3.0 mm tube)
Newborn 3.0-3.5 mm tube
Up to 6 months of age 3.5 mm tube
note should measure child with the length-based resuscitation tape - measure from topof head to infant or child's heel
At one year of age need at least a 4.0 mm
tube
MGH Quick Method forUncuffed Tubes
1 yr 4 mm 10 kg
5 yrs 5 mm 20 kg
8-10 yrs 6 mm 30 kg
Extrapolate in between (e.g. 2 year old
=4.5mm ETT
7/24/2019 intubacion app
13/31
Length-based resuscitation tape
Measure from head to heel of patient (3-36 kg)
Cuffed vs Uncuffed Tubes
Sizing:
less than standard formula (except for 3.0 mm)
When do you use a cuffed tube?
Any patient that may require high pressures to
ventilate
Can use it in any critically ill or injured infant or child
Studies show same frequency of subglottic stenosiswith cuffed tubes and less need for tube exchange
7/24/2019 intubacion app
14/31
Laryngoscope Blade Size
Miller Macintosh
Blade size Miller 0 - premature infant or
small newborn
Miller 1 - normal newborn to
12 kg (2 years)
Miller 2 - 13 to 24 kg (7 years)
Miller 3 - 25 kg + (8 years +)
Too small a blade can get you into trouble
Macintosh may be usedafter 2 years of age
Miller 2
after age 2
7/24/2019 intubacion app
15/31
Depth of tube placement
Watch vocal cord marker go past
the cords
Depth of tube placement in cm
can be calculated as 3 X size of
tube:
(Example: 3.5 mm tube
would be placed at 10.5 cm at
the lip)
Depth can also be determined by
use of a length-basedresuscitation tape or by use of an
illuminated ETT
ET placement
7/24/2019 intubacion app
16/31
Confirmation of tube placement
Clinical assessment
CO2 detection or monitor
Esophageal detection device (EDD)
Bulb or syringe
Chest radiograph
Pulse oximetry
ETT is too low
Complications post ETI
DOPE:
Dislodgement
Obstruction/Oxygen
Pneumothorax
Equipment fails
7/24/2019 intubacion app
17/31
ETI: Lessons Learned
Place blade in just to the base of the tongue and
look for cords
If cant see anything but pink you are too far in -
back blade out a little bit or lighten cricoid pressure
If the blade is all the way in and you see the
epiglottis your blade is too small
If you see the epiglottis - advance blade a little
further
Get on you knees and look up its anterior
Foreign Body Aspiration Begin with BLS maneuvers
Infant: Back blows (5) and
chest thrusts (5)
Child:
If conscious, abdominal
thrusts/Heimlich
Maneuver (5 per cycle)
If unconscious performchest compressions
ALS maneuvers if BLS fails
Use Magill forceps to
remove the foreign body
7/24/2019 intubacion app
18/31
Rapid Sequence Intubation (RSI):
7 Steps
Preparation
Preoxygenation
Pretreatment
Paralysis with induction
Protection and positioning
Placement of ET tube in trachea
Postintubation management
Order and steps
dependent on clinical
situation
Preoxygenation
Add100%oxygen
Rememberinfantsbecomehypoxicquicklyrelativelysmallreservoirinnasopharynx andlung
Nighmetabolicratevs adults
Highflownasalcannula (515Lpermin)canpreventhypoxiaduringapneicperiod
http://cagle.msnbc.com/news/FAT07/images/parker.gif http://www.mhsks.org/assets/Infant.jpg
7/24/2019 intubacion app
19/31
Net pressure in the alveoli is subatmospheric
leading to apneic oxygenation
Achieving apneic oxygenation:
Use nasal cannula in the nonbreathing patient
the oxygen will fill the reservoir of the
nasopharynx
Children/Adults 15+L/min
Infants/Toddlers 5+L/min ????
\
HFNC and RSI
Weingart SDandLevitan RM:AnnEmergMed2011
Pretreatment
Atropine [0.02 mg/kg; min 0.1 mg; max 0.5 mg]
Pathophysiology Paucity of sympathetic nerves to ventricles makes
them less electrically stable
Sympathetic-parasympathetic imbalance results inaccelerations and decelerations
Guidelines (APLS) - controversial Use in infants < 1 year
Children 1-5 years who receive succinylcholine
Others who receive second dose ofsuccinylcholine
7/24/2019 intubacion app
20/31
Bean A: EMJ/BMJ 2011
Reviewed literature on use of atropine to preventbradycardia in children during RSI
112 papers found 2 presented best evidence Evidence from these two studies would indicate that
the incidence of reflex bradycardia in children duringrapid sequence intubation (RSI) is much lower thanpreviously thought.
Furthermore, it does not appear the paralysing agentused significantly contributes to incidences ofbradycardia.
It appears that hypoxia, not foregoing pre-treatment
with atropine, is a stronger predictor of patients whowill develop reflex bradycardia following RSI.
Orjust have it available when you need it
Sedative Selection
Hypotension: Ketamine if concerned about
sepsis
Bronchoconstriction: Ketamine
Head injury without hypotension (or signs
of shock): Etomidate or thiopental or
midazolam Head injury with hypotension: Etomidate
or ketamine
7/24/2019 intubacion app
21/31
Neuromuscular Blocking Agents
Succinylcholine 2-3 mg/kg
ONLY depolarizing NMB: Binds to the Ach receptor
on the motor endplate and depolarizes the
postjunctional neuromuscular membrane
Onset 30-60 sec, duration 3-8 min
Shorter duration (plasma cholinesterase hydrolyzes), higher
risk of adverse effects
Rocuronium 1 mg/kg
Competitively block ACH transmission at the
postjunction cholinergic nicotinic receptor Onset 1-3 min, duration 25-35 min
Longer duration, but less potential for adverse effects
Do not under dose in childrencan give 3 mg/kg
in young infants [greater volume of distribution]
Ventilator Management:
Ventilator settings are adjusted based onpatients clinical status
Chest rise, pulse oximetry, peak inspiratorypressure, end tidal CO2 and blood gasanalysis
Selection of tidal volume based on thefollowing generally 6-8 mL/kg:
Visible chest excursion simulating normalbreathing
Audible air entry
Diminution of dyspnea
7/24/2019 intubacion app
22/31
Case: 2 year-old boy
Mother rushes into triage with a 2 year-old boy
with a craniofacial abnormality
The child is obtunded with gasping respirations
and skin color is pale
The nurse calls for a physician and places the
child immediately in the resuscitation room
You attempt BMV but are unable to get a seal;
O2 sat is 70%; small jaw makes ETI impossible
What is your next airway option?
Management techniques:
Consider placement of OP or NP airway/ BMV
Supraglottic/Extraglottic airway - Laryngeal mask airway(LMA), iGel, Air-Q, Laryngeal tube/King Airway
Intubate using other methods Video laryngoscopy
Lighted stylet or Lightwand
Fiberoptic intubation
Other Elastic Gum Bougie (not for kids- age 14 years+) Combitube (not for kids age 14 yrs +)
Cricothyrotomy (needle children < 6 years?) if otherrescue devices fail and cannot BMV
7/24/2019 intubacion app
23/31
Extraglottic/Supraglottic Devices
Air-Q able to intubatethrough the device 3studies in children
i-gel single-use with non-inflatable cuff composed ofthermoplastic elastomer andsoft gel cuff has airwaytube and gastric tube [one study
in 50 children in OR good insertion ratesand few complication rates]
LMA Sizing on Broselow Tape
Sizing found on Broselow-LutenTape (2002 edition or greater)
LMA-Supreme
7/24/2019 intubacion app
24/31
LMA Placement
King Laryngeal Airway
King systems Laryngeal tube(Noblesville, IN)
Supraglottic airwaydevice with a singlelumen
Passed blindly into theesophagus
Available in 5 sizes
Can be used in children>12 kg or 36 inches
Few data in children
http://www.kingsystems.com
7/24/2019 intubacion app
25/31
Video Laryngoscopy
Routine or the difficult airway?
Why use it?
Offers expanded view
Magnified view enhances visualization
Can be performed with neutral neck position
Can be performed with reduced oral opening
Educational advantages share the view orrecord attempt for teaching, performance
improvement
Video Laryngoscopy in Pediatrics
Device Classification Patient Size Manufacturer/
Distributer
Airtraq Channeled
device/optical
laryngoscope
Infant, child,
adolescent
Prodol/ King
Systems
Berci-Kaplan DCI
C-MAC
VL Neonate, infant,
child, adolescent
Karl Storz
Endoscopy
Glidescope GVL,
Cobalt, Ranger
VL Neonate, infant,
child, adolescent
Verathon Medical
McGrath Series 5 VL Adolescent Aircraft Medical/
LMA North America
Pentax AWS VL, channeled
device
Adolescent Pentax/ Ambu
Truview EVO2 Optical laryngocope
with video capability
Infant Truphatek
International
Angulated Video-
Intubation
laryngoscope
VL Child, adolescent Volpi
[Not available in US]
7/24/2019 intubacion app
26/31
Video Laryngoscopy
Increasing use of video
laryngoscopy for routine
intubations
Still primarily used for the
difficult airway
Devices vary in cost and
portability
GlideScope most widely
used at this point but others
have advantages
Pediatric Airway Management
Airway management is a
process involving
assessment followed by
interventions followed by
reassessment begin with
basics
Children can be daunting
because of sizingissueskeep tools available
to help!
Master basic and advanced
techniques
7/24/2019 intubacion app
27/31
References
Holm-Knudsen RJ, Rasmussen LS. Pediatric Airway Management:Basic Aspects. Acta Anaesthesiol Scand 2009;53:1-9.
Barata I. The Laryngeal Mask Airway: Prehospital and EmergencyDepartment Use. Emergency Medicine Clinical North America2008;26:1069-1083.
Chen L, Hsiao AL. Randomized Trial of Endotracheal Tube VersusLaryngeal Mask Airway in Simulated Prehospital Pediatric Arrest.Pediatrics 2008;122:e294-297.
Duyndam A, et al: Invasive ventilation modes in children: A systematicreview and meta-analysis. Crit Care 2011;15:R24 epub ahead of print
Grein AJ, Weiner GM. Laryngeal Mask Airway versus Bag-maskVentilation or Endotracheal Intubation for Neonatal Resuscitation.Cochrane Database System Rev 2005:18:CD003314.
Kerrey BT, Geis GL, Quinn AM, Hornung RW, Ruddy RM. A ProspectiveComparison of Diaphragmatic Ultrasound and Chest Radiography toDetermine Endotracheal Tube Position in a Pediatric Emergency
Department. Pediatrics 2009;123:e1039-1044.
References
RSI: Bean A. Atropine: Re-evaluating its use during paediatric RSI.
Emerg Med J 2007;24:361-362.
Ching KY, Baum CR: Newer agents for rapid sequenceintubation Pediatr Emerg Care 2009;25:200-210.
Fastle R, Roback M: Pediatric Rapid Sequence Intubation:Incidence of Reflex Bradycardia and Effects of PretreatmentWith Atropine. Pediatr Emerg Care 2004;20(10):651-655.
Lecky F, Bryden D, Little R, Tong N, Moulton C. EmergencyIntubation for Acutely Ill and Injured Patients. Cochrane
Database Syst Rev. 2008;16:CD001429. Weingart SD: Preoxygenation, reoxygenation, and delayed
sequence intubation in the emergency department. J Emerg Med
2011;40(6):661-667.
Weingart SD, Levitan RM. Preoxygenation and prevention of
desaturation during emergency airway management. Ann Emerg
Med 2011; [EPub ahead of print]
7/24/2019 intubacion app
28/31
References
RSI Lemyre B, et al: Atropine, fentanyl and succinycholine for non-urgent
intubations in newborns. Arch Dis Chil Fetal Neonatal Ed 2009;94:F439-F442.
Mace SE. Challenges and Advances in Intubation: Airway Evaluationand Controversies with Intubation. Emerg Med Clin N Am 2008;26:977-1000.
Nagler J, Bachur RG. Advanced Airway Management. Curr OpinPediatr2009;21:299-305.
Waage NS, Baker S, Sedano HO. Pediatric Conditions Associated withCompromised Airway: Part 1--congenital. Pediatr Dent 2009;31:236-248.
Zuckerbraun NS, Pitetti RD, Herr SM, Roth KR, Gaines BA, et al. Useof Etomidate as an Induction Agent for Rapid Sequence Intubation in aPediatric Emergency Department. Acad Emerg Med 2006;13:602-609.
Zelicof-Paul A, et al: Controversies inrapid sequence intubation inchidlren. Curr Opin Pediatr2005;17:355-362.
References
Cricoid Pressure Brock-Utne JG: Is cricoid pressure necessary? Paediatric
Anesthesia 2002;12:1-4.
Butler J. Cricoid pressure in emergency rapid sequenceinduction. Emerg Med J 2005;22:815-816.
Ellis DY, Harris T, Zideman D: Cricoid pressure in emergencydepartment rapid sequence intubations: A risk benefit analysis.
Ann Emerg Med 2007;6:653-663.
Engelhardt T, Strachan L, Johnston G. Aspiration andregurgitation in paediatric anaesthesia. Paed Anaesth
2001;11:147-150. Sellick BA. Cricoid pressure to prevent regurgitation of stomach
contents during induction of anesthesia. Lancet 1961;2:404-406.
Salem MR, Sellick BA, Elam JO. The historical background ofcricoid pressure in anesthesia and resuscitation.Anesth Analg1974;53(2):230-2.
7/24/2019 intubacion app
29/31
References:
Jaw thrust: Bruppacher H, Reber A, Keller JP, Geiduschek J,
Erb TO, et al. The Effects of Common AirwayManeuvers on Airway Pressure and Flow inChildren Undergoing Adenoidectomies.International Anesthesia Research Society2003;97:29-34.
Arai YC, Fukunaga K, Hirota S, Fujimoto S. TheEffects of Chin Lift and Jaw Thrust While in theLateral Position on Stridor Score in AnesthetizedChildren with Adenotonsillar Hypertrophy.International Anesthesia Research Society
2004;99:1638-1641.
References
Use of cuffed ET tubes in children: Engelhardt T, Johnston G, Kumar M. Comparison
of Cuffed, Uncuffed Tracheal Tubes and LaryngealMask Airways in Low Flow Pressure ControlledVentilation in Children. Pediatric Anesthesia2006;16:140-143.
Ho A. Cuffed versus Uncuffed PediatricEndotracheal Tubes. Can J Anesth 2006;53:106-111.
Newth C, Rachman B, Patel N, Hammer J. TheUse of Cuffed Versus Uncuffed Endotracheal Tubesin Pediatric Intensive Care. The Journal ofPediatrics 2004;144:333-337.
7/24/2019 intubacion app
30/31
Video Laryngoscopy: References
Armstrong J, John J, Karsli. A comparison between the GlideScope VideoLaryngoscope and direct laryngoscope in pediatric patients with a difficultairway.Anesthesia. 2010;65:353-7.
Cooper RM, Pacey JA, Bishop MJ, McCluskey SA, Early Clinical experiencewith a new videolaryngoscope (GlideScope) in 728 patients. Can J Anesth2005; 52: 191-198
Hsu WT, Hsu SC, Lee YL, Huang JS, Chen CL. Penetrating injury of thesoft palate during GlideScope intubation. Anesth Analg 2007; 104: 1610-1611
Hurford DM, White MC. A comparison of the GlideScope and Karl Storz DCIvideolaryngoscopes in a paediatric manikin. Anaesthesia. 2010; 65:781-4.
Inal MT, Memis D, Kargi M, Oktay Z, Sut N: Comparison of TruView EVO2with Miller laryngoscope in paediatric patients. Eur J Anaesthesiol 2010Nov;27(11):950-4.
Kim JT, Na HS, Bae JY, Kim DW, Kim HS, Kim CS, Kim SD. GlideScopevideo laryngoscope: A randomised clinical trial in 203 paediatric patients. Br
J Anaesth 2008;101:531-534.
Video Laryngoscopy: References
Karsli C, Der T. Tracheal intubation in older children with severeretro/micrognathia using the GlideScope Cobalt Infant VideoLaryngoscope. Paediatr Anaesth. 2010; 20(6): 577-8.
Malik MA, ODonoghue C, Carney J, Maharaj CH, Harte BH, Laffey JG.Comparison of the GlideScope, the Pentax AWS, and the Tru- viewEVO2 with the Macintosh laryngoscope in experienced anaesthetists: amanikin study. Br J Anaesth. 2009; 102:128-134
Milne AD, Dower AM, Hackmann T. Airway management using thepediatric GlideScope in a child with Goldenhar syndrome and atypicalplasma cholinesterase. Paediatr Anaesth. 2007; 17(5): 484-7.
Singh R, Singh P, Vajifdar H: A comparison of TRuview infant EVO2laryngoscope with the Miller blade in neonates and infants. Peds
Anesthesia 2009;19(4):338-42. Taub PJ, Silver L, Gooden CK. Use of the GlideScope for airway
management in patients with craniofacial anomalies. Plast ReconstrSurg. 2008;121:237-8
White M, Weale N, Nolan J, Sale S, Bayley G. Comparison of the CobaltGlideScope video laryngoscope with conventional laryngoscopy insimulated normal and difficult infant airway. Pediatric Anesthesia. 2009;19:1108-12.
7/24/2019 intubacion app
31/31
References
AHA Kleinman ME, et al: Part 14: Pediatric Advanced Life Support:
2010 American Heart Association Guidelines forCardiopulmonary Resuscitation and Emergency CardiovascularCare. Circulation 2010;122:S876-2908.
Berg MD, et al: Part 13: Pediatric Basic Life Support: 2010American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency Cardiovascular Care. Circulation2010;122:S862-875.
Kattwinkel J, et al: Part 15: Neonatal resuscitation: 2010American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency Cardiovascular Care. Circulation2010;122:S909-919.
References
Resuscitation:
Kitamura T, et al: Conventional and chest-compression-only
CPR by bystanders for children who have out-of-hospital
arrests: A prospective, nationwide-population-based cohort
study. Lancet 2010;375:1347-1354.
Kleinman ME, et al: Pediatric Basic and Advanced Life
Support: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Pediatrics2010;126;e1261-e1318.