Pediatric airway obstruction

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Transcript of Pediatric airway obstruction

  • 1.Pediatric Airway Obstruction Ibrahim Habib Barakat , MD

2. The Pediatric Airway Introduction Normal Anatomy Physiology Airway evaluation Management ofnormal vs.abnormal airway Difficult airway 3. Introduction Almost all of pediatric codes are due torespiratory origin 80% of pediatric cardiopulmonary arrest areprimarily due to respiratory distress Majority of cardiopulmonary arrest occur at 7 mm @ C2Retrotracheal space :14 [email protected] C6 .. Ped22 mm @ C6 .. Adult 37. F. B. ingestion 38. MRI/CTUsually not useful in an acute settingMore reliable for evaluating neck masses andcongenital anomalies of the lower airwayand vascular system 39. Diagnostic Testing Perform radiograph exam only when there is noimmediate threat to the childs safety and in thepresence of skilled personnel with appropriateequipment to manage the airwayIntubation must not be postponed to obtainradiographic diagnosis when the patient isseverely compromised. Blood gases are helpful in assessing the degree ofphysiologic compromise; however, performing anarterial puncture on a stressed child mayaggravate the underlying airway obstruction 40. Flexible Laryngoscopy: Proper Equipment Assess nares/choanae Assess adenoid andlingual tonsil Assess TVC mobility Assess laryngealstructures 41. Airway Management: Normal Airway Challenging because of unique anatomy and physiology Goals: protect the airway, adequately ventilate, and adequately oxygenate Failure to perform any ONE of these tasks will result in respiratory failure Positioning is key! 42. Bag-Mask VentilationClear, plastic mask with inflatable rimPlace fingers on mandible to avoidprovides atraumatic sealcompressing pharyngeal spaceHand on ventilating bag at all times toProper area for mask application-bridgemonitor effectiveness of spontaneous breathsof nose extend to chinContinous postitive pressure when neededMaintain airway pressures 1hr, coughing on ETT, URI, h/o croup Tx: humidified mist, nebulized racemicepinephrine, steroid 52. Complications of Endotracheal Intubation Laryngotracheal (Subglottic) Stenosis Occurs in 90% of prolonged endotracheal intubation Lower incidence in preterm infants and neonates due to relative immaturity of cricoid cartilage Pathogenesis: ischemic injury secondary to lateral wall pressure from ETT edema, necrosis, and ulceration of mucosa, infx Granulation tissues form within 48hrs leads to scarring and stenosis 53. Cuff vs Uncuffed Endotracheal Tube Controversial issue Traditionally, uncuffed ETT recommended inchildren < 8 yrs old to avoid post-extubationstridor and subglottic stenosis Arguments against cuffed ETT: smaller sizeincreases airway resistance, increase work ofbreathing, poorly designed for pediatric pts, needto keep cuff pressure < 25 cm H2O Arguments against uncuffed ETT: more tubechanges for long-term intubation, leak ofanesthetic agent into environment, require morefresh gas flow > 2L/min, higher risk foraspiration 54. Cuff vs Uncuffed Endotracheal Tube -Concluding Recommendations- For short cases when ETT size >4.0, choice ofcuff vs uncuffed probably does not matter Cuffed ETT preferable in cases of: high risk ofaspiration (ie. Bowel obstruction), low lungcompliance (ie. ARDS, pneumoperitoneum, CO2insufflation of the thorax, CABG), precise controlof ventilation and pCO2 (ie. increased intracranialpressure, single ventricle physiology) 55. Laryngeal Mask Airway Supraglottic airway device developed by Dr.Archie Brain Flexible bronchoscopy, radiotherapy, radiologicprocedures, urologic, orthopedic, ENT andophthalmologic cases are most common pediatricindications for LMA Useful in difficult airway situations, and as aconduit of drug administration (ie. Surfactant) Different types of LMAs: Classic LMA, FlexibleLMA, ProSeal LMA, Intubating LMA Disadvantages: Laryngospasm, aspiration 56. Laryngeal Mask AirwayLMA size WeightMax cuff volume (mL) ETT (mID) 1 .0 Neonate/Infants 5kg43.5 1.5Infants 5-10kg7 4.0 2.0Infants/children 10-20kg104.5 2.5Children 20-30kg145.0 3.0Children/small adult > 30kg 206.0 cuff 4.0Normal/large adolescent/adult 307.0 cuff 5.0Large adolescent/adult408.0 cuff 57. Other Supraglottic Devices Laryngeal tube Latex-free, single-lumen silicone tube, which is closed at distal end Two high volume-low pressure cuffs, a large proximal oropharyngealcuff and a smaller distal esophageal cuff Both cuffs inflated simultaneously via a single port Situated along length of oropharynx with distal tip in esophagus Sizes 0-5, neonates to large adults (only sizes 3-5 available in US) Limited data available for its use in children 58. Other Supraglottic Devices Cobra Perilaryngeal Airway Perilaryngeal airway device with distal end shaped like a cobra-head Positioned into aryepiglottic folds and directly seats on entrance toglottis Inflation of the cuff occludes the nasopharynx pushing the tongue andsoft tissues forward and preventing air leak Available in sizes pediatric to adult to 6 No studies currently available evaluating this device in children 59. Difficult Airway Management Techniques Rigid bronchoscopy Flexible bronchoscopy Direct laryngoscopy Intubating LMA Lighted stylet Bullardscope Fiberoptic intubation Surgical airway 60. TracheotomyCricothyroidotomy is difficult b/c of small membrane and flexibilityEarly complicationsPneumothorax, bleeding,decannulation, obstruction,infectionsLate complicationsGranuloma, decannulation,SGS, tracheocutaneousfistula 61. Airway ManagementClassification of Abnormal Pediatric Airway Congenital Neck Masses (Dermoid cysts,cystic teratomas, cystic hygroma,lymphangiomas, neurofibroma, lymphoma,hemangioma) Congenital Anomalies (Choanalatresia,tracheoesophageal fistula, tracheomalacia,laryngomalacia, laryngeal stenosis, laryngealweb, vascular ring, tracheal stenosis) Congenital Syndromes (Pierre RobinSyndrome, Treacher Collin, Turner, Downs,Goldenhar , Apert, Achondroplasia, Hallermann-Streiff, Crouzan) 62. Airway ManagementClassification of Abnormal Pediatric Airway Inflammatory (Epiglottitis, acute tonsillitis,peritonsillar abscess,retropharyngeal abscess,laryngotracheobronchitis,bacterial tracheitis,adenoidalhypertrophy,nasal congestion, juvenile rheumatoidarthritis) Traumatic/Foreign Body(burn,laceration,lymphatic/venousobstruction,fractures/dislocation, inhalationalinjury, postintubation croup (edema),swelling ofuvula Metabolic (Congenital hypothyroidism,mucopolysaccharidosis, Beckwith-WiedemannSyndrome,glycogen storage disease, hypocalcemialaryngospasm) 63. Congenital Neck Masses 64. Congenital Neck Masses 65. Congenital AnomaliesTracheoesphageal Fistula 66. Congenital AnomaliesTracheoesphageal FistulaFeeding difficulties (coughing, choking and cyanosis) and breathing problemsAssociated with congenital heart (VSA, PDA, TOF), VATER, GI, musculoskeletal and urinary tract defectsOccurs in 1/ 3000-5000 birthsMost common type is the blind esophageal pouch with a fistula between the trachea and the distal esophagus (87%) 67. Congenital AnomaliesTracheoesphageal Fistula Radiograph of a neonate with suspected esophageal atresia. Note the nasogastric tube coiled in the proximal esophageal pouch (solid arrow). The prominent gastric bubble indicates a concurrent tracheoesphageal fistula (open arrow) 68. Congenital Anomalies Choanal Atresia Complete nasal obstructionof the newborn Occurs in 0.82/10 000births During inspiration, tonguepulled to palate, obstructsoral airway Unilateral nare (right>left) Bilateral choanal atresia isairway emergency Death by asphyxia Associated with othercongenital defects 69. Congenital AnomaliesChoanal Atresia 70. Clinical manifestations- unilateral :Asymptomatic for along period till the first attack of upper respiratory tract infection,diagnosis may be suggested by nasal discharge or persistent nasal obstruction .- bilateral :Difficulty with mouth breathing make vigerous attempts to inspire , often suck in their lips ,and develop cyanosis . Distressed children then cry ( which relieve the cyanosis ) and become more calm with normal skin colour , only to repeat the cycle after closing their mouths . Those who are able to breath through their mouths at once experience difficulty when suckling and swallowing , becoming cyanotic when they attempt to feed . 71. diagnosis - inablity to pass afirm cather 3 to 4 cminto the nasopharynx through each nostril . - the atritic plate can be seen directly withfibro optic rhinoscopy . -the anatomy is best evaluated by usinghigh resolution CT scan . 72. treatment - bilateral : - - An oral airway or intubation . - trasnasal endoscopic surgical repair . - stents are usually left in place after the repair forweeks to prevent restenosis or closure . - tracheostomy should be considered in child hasother potentially life threatening problems and inwhom early surgical repair of the choanal atresiamay not be appropriate or feasible . 73. treatment - unilateral :- - operative correction may be deffered forseveral years - in both nuilateral or bilateral cases ,restenosis necessitating dilatation orreoperation , or both , is common . - mitomycin-c has been used to helpprevent the development of granulationtissue and stenosis . 74. Congenital Syndromes Pierre Robin Sequence Occurs in 1/8500 births Autosomal recessive Mandibular hypoplasia, micrognathia,cleft palate, retraction of inferior dentalarch, glossptosis Severe respiratory and feedingdifficulties Associated with OSA, otitis media,hearing loss, speech defect, ocularanomalies, cardiac defects,musculoskeletal (syndactyly, club feet),CNS delay, GU defects) 75. Congenital SyndromesPierre Robin Sequence 76. Congenital SyndromeTreacher Collins Syndrome Mandibulofacial dysotosis Occurs in 1/10 000 births Cheek bone and jaw bone underdeveloped External ear anamolies, drooping lowereyelid, unilateral absent thumb Respiratory difficulties Underdeveloped jaw causes tongue to bepositioned further back in throat (smallerairway) Associated with OSA, hearing loss, dryeyes 77. Congen