Pat Thorpe, MSN,CPN Clinical Co coordinator - PowerPoint Presentation

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Pat Thorpe, MSN,CPNClinical Co coordinatorGarfield Watson rtPediatric Intensive care unitNicklaus Children HospitalSeptember 26,2017

Airway Management in Pediatric Patients

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FactsAppropriate airway management is the key to success in pediatric patients.Most pediatric cardiac arrests begin with respiratory arrest.Anatomy and physiology of pediatric airway varies from those of adults. Effective airway management includes anticipating and planning for problems.Impaired breathing affects the gas exchange in the lungs, thereby causing low oxygen level and high carbon dioxide level un the blood.

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OverviewDiscuss the differences between pediatric and adult airwaysDiscuss the various oxygen delivery systemDiscuss various airway modesIdentify conditions of respiratory comprise in childrenManagement of Respiratory failureBag –Mask Ventilation

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Features of Pediatric AirwayNarrower airway hence easily obstructedForeign body, edema, secretions blood Larger tongue which is posteriorly displacedLonger and floppy epiglottisHigher anterior larynx

Narrower vocal cord, making intubation more difficult

Shorter trachea

Larger head.

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Adult vs. Child

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Pediatric Airway Positioning

Incorrect Positions

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Pediatric Airway Positioning contd.

Correct Position

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Oxygen Delivery SystemsBasicNasal Cannula : FIo2 24-40% - 6LPM Face Mask : FIO2 30-60% - 6-12 LPMFace Tent : 10-15 LPMRebreather/Non Rebreather Mask : 100%Venturi Mask: 25-60% (color coded nozzles)

Oxygen Tent : 30-50%

Oxygen Hood: 80-90%

Trach Collar

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Oxygen Delivery System contdAdvancedVapothermCPAP (Continuous positive airway pressure)Bi-PAP (Bi-level positive airway pressure)VentilatorOscillator (HFOV)

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Ventilators Conventional

Oscillator

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Vapotherm/High flow

Vapotherm

High Flow

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Bipap

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Artificial Airway ModesArtificial airways are used to establish patent airway and facilitate respirationOropharyngeal ( Oral airway)Nasopharyngeal (Nasal Trumpet)Laryngeal Mask Airway (LMA)Endotracheal/

Nasotracheal

Tube (ETT)

Tracheostomy Tubes

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Oropharyngeal/ Oral AirwaysNot usually used in conscious children - vomiting riskPrevents the tongue from falling back and occluding pharynx Facilitates in secretion removalShort term use onlyMay be used to prevent biting of orotracheal tube

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Nasopharyngeal Airways May be used in conscious and unconscious patients in maintaining airway patencySoft rubber or plastic tubesProvide opening from nares to posterior pharyngeal wall Provide access to pharyngeal suctioning

Often become compressed or obstructed

Could require frequent suctioning to maintain patency

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Laryngeal Mask Airway Used in unconscious patients without intact gag/ cough reflexesA tube with a balloon mask at the end to seal the hypopharynxAlternate to endotracheal intubationAble to use with mechanical ventilationDoes not protect against aspirationSelection is based on patient size: eg. Size 1 (infant) to size 5 (adults)

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Endotracheal TubesOral or nasalInserted for respiratory failure requiring mechanical ventilationMay have “cuffs” at the distal end to seal the trachea, preventing air leaks around the tube

Smallest size: 2.0 uncuffed

Largest size: 10.5 cuffed

Sizing Equation:

(age in years/4) +4 = ETT size

Equal to the child’s pinky or nares width

May also use Broselow Resuscitation Tape,

based on child’s length.

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Endotracheal tubes contdInsertionUsing laryngoscope with Mac (curved-children and adults) or Miller (straight-infants), the epiglottis is lifted, and the ETT is passed between the vocal cords into the tracheaPatient is sedated and paralyzed When intubated the depth of tube should be

3 x ETT size.

Position is confirmed by Pedi-cap/ETCO2

dectector

, 0xygen saturation, breath sounds, chest expansion, chest x-ray and water vapor inside the tube.

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Supplies Needed for Intubation

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Surgical opening in the tracheaEmergent or Elective placementSizing depends on size of the child; based on physical measurementCuffed or UncuffedCommon types: Shiley, Bivona, Bivona Flex tend (for the chubby-necked).Tracheostomy Tubes

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Immediate post-operative management Patients with fresh trachs are treated as a CRITICAL AIRWAY until the first trach change is done on POD 7

Humidification

Over: Excessive secretions, requires frequent suctioning

Under: Secretions too thick, at risk for plugging trach

Sutures help to keep the stoma open. They are often secured to the chest with tape. If they are not, make sure they are visible and easily accessible

Full trach care with tie change is postponed until after the first trach change

If trach becomes displaced and you are unable to reinsert call for staff assist/ Code Blue. Anesthesia or ENT/Surgery may needed for re insertion.

Tracheostomy

Tubes contd.

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Emergency equipment – must be with child at all timesAmbu bagOxygenSuction

Suction catheters

Lavage

Obturator

Extra trachs

Same size

One size smaller

One size bigger

Post-operative complications

Accidental decannulation

Tube obstruction

Air leak

Free air in pleural cavity

Edema of the chest and neck

Hemorrhage

False passage

Tracheostomy Tubes contd

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SuctioningPrior to first suction, use an extra trach, to measure the appropriate suction depthSuction catheter should extend just beyond the distal end of the trachCatheter size approx. twice the trach size

Suction using sterile technique

Child may need sterile saline lavage if secretions are thick. Only use 1-2

mls

– sparingly!!

May need supplemental oxygen or

ambu-ing

to recover saturations after suctioning

Duration of suctioning (10-15 seconds)

Tracheostomy tubes contd.

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Respiratory Distress Signs and SymptomsTachypnea, Tachycardia, Agitation,Grunting, Flaring, Retractions

Wheezing, Stridor, Inability to lie down

Use of Accessory muscles, Sweating

Head bobbing, Cyanosis, Apnea

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Respiratory Failure Signs & Symptoms

Increased WOB

Decreased lung volumes/alveolar collapse

Upper airway obstruction- stridor and retraction

Lower airway obstruction- wheezing

Decreased air entry

Compromised perfusion

Altered LOC

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Respiratory FailureManagementPrevention*

Non-invasive monitoring –pulse ox

Invasive monitoring – blood gases

Supplemental O

2

Mechanical ventilation

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Used to support patients with inadequate respiratory effortPositioning is key in performing adequate BMV3 key pointsMaintain open airwayEstablish seal between mask and face

Deliver optimal breath volume and respiratory rate

BAG-MASK VENTILATION

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BAG-MASK VENTILATION

Proper

Position

Maintain jaw thrust

Place

3 fingers under the

bony

aspect of the mandible and lift

Be careful of where your fingers land!

Jaw

thrusting will automatically

position

the

head in a “neutral sniffing” position

It is not necessary to hyperextend the

neck

, especially in infants and

toddle

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BAG-MASK VENTILATIONEnsuring proper sealE-C clamp techniqueThumb and forefinger

form

C-shape

Downward pressure on

the

mask

Last 3 fingers apply

pressure

to mandible

Lift face up to mask

DO NOT PUSH THE MASK

DOWN

ON THE FACE –

this

will occlude the airway

and

render BMV

ineffective

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Assessing adequate Bag-Mask VentilationLook for chest riseListen for bilateral breath soundsNote vital signsAssess patient’s color and perfusion

Monitor oxygen saturation

BAG-MASK VENTILATION