introduction to the picu and airway management uthscsa pediatric resident curriculum for the picu
TRANSCRIPT
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Introduction to the PICU and Airway Management
UTHSCSA Pediatric Resident Curriculum for the PICU
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The Purpose of Intensive Care
Units exist to monitor patients for acute deterioration
Units are staffed by personnel trained to react to deterioration with advanced skills
Success in management favors the prepared mind
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Keys to Success
Perform the same approach on every patient each day
Collect information (exam, notes, labs) construct a coherent picture, develop an assessment and formulate a plan
Present in a consistent manner Predict what problems may develop
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Airway Management
The ability to recognize impending respiratory failure and stabilize an airway is one of the cornerstones of ICU management
Knowledge of the pediatric airway and proficiency in its stabilization and intubation is essential
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Laryngeal Cartilages
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Laryngeal Anatomy (Infant)
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Laryngeal Anatomy
Sensory innervation occurs from the internal branch of the superior and recurrent laryngeal nerve, motor innervation is from the recurrent laryngeal nerve
Blood supply is provided by the superior and inferior thyroid arteries
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Four Differences between the Adult and Pediatric Airway• Infant tongue is proportionally large• The infants larynx is higher (rostral) in the
neck (C3-4) than an adults (C4-5)• The infants epiglottis is omega shaped ()
and angled away from the trachea• The narrowest part of the larynx is the cricoid
cartilage below the vocal cords
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Larynx Configuration
Adult (cylinder) Pediatric (funnel)
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Airway Diameter and Resistance
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Obstructed Inspiration/Expiration
Stridor Wheezing
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Work of Breathing
Product of Compliance and Resistance Nasal passages account for 25% of airflow
resistance in infants, 60% in adults Most resistance in infants occurs in the small
airways– small diameter– lack of supporting structures
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Work of Breathing
WOB per kilogram body weigh is similar in adults and children. Higher respiratory rates are due to greater O2 consumption
– (4-6 ml/kg/min) infants, (2-3 ml/kg/min) adults
Infant have diaphragm and intercostal muscles with fewer Type 1 (slow-twitch) fibers so they are more prone to fatigue
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Airway Management
The Goal of Airway management is to anticipate and recognize respiratory problems and to support or replace those that are compromised or lost
Pediatric Advance Life Support Manual
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Important to Remember
An individual must be able to support three specific functions:– Protect their airway– Adequately ventilate– Adequately oxygenate
A failure to perform any ONE function will result in respiratory failure.
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Airway Control
There are many simple, non-invasive techniques to support respiration prior to undertaking endotracheal intubation– Application of oxygen– Suctioning– Positioning of the airway– Application of positive pressure– Assistance of ventilation with a BVM
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Application of Oxygen
Nasal canula (23-25%) Simple face mask (35-60%) Non-rebreather mask (80-100%)
– High flow (10-12 l/min)– Reservoir of oxygen– Tight-fitting to face– Valves to prevent entrainment of room air
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Suctioning
The inability of infants to generate a strong cough together with their small airways makes removal of tracheal secretions important to assure patency
Infants are obligate nasal breathers and become unruly when their nose is obstructed. Many an infant was saved from intubation by a bulb suction!
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POSITIONING
Use of the chin lift and jaw thrust can help restore flow through an obstructed upper airway by separating the tongue from posterior pharyngeal structures.
The goal is to line up three divergent axes: oral, pharyngeal and tracheal.
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Aligning the Axes (Initial)
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Aligning the Axis (Occiput Roll)
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Aligning the Axis (Extension)
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Oropharyngeal Airways
Facilitates relief of upper airway obstruction due to a large tongue
Allows oropharyngeal suctioning Prevents compression of a child’s
endotracheal tube due to biting.
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Oropharyngeal Tube Selection
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Bag-Valve-Mask
Masks should fit easily over the nose and mouth with no pressure on the eyes The base of the mask rests on the chin
Valves allow unidirectional flow of oxygen to the patient and prevent entrainment of exhaled waste gas into the system
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Bag-Valve-Mask
There are two types of bags, anesthesia and self-inflating
Anesthesia bags require a perfectly closed system to operate and allow finer control of inspiratory and expiratory pressures.
Without oxygen flow, the bag will not inflate.
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Anesthesia Bag
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Self-Inflating Bag
Allows rapid ventilation of a patient in an emergency because it does not need an oxygen source to operate
Requires the use of a reservoir to deliver 100% oxygen, otherwise it entrains some room air with the oxygen
Requires a PEEP valve to deliver specific end-expiratory pressures.
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Self-Inflating Bag
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Preparation for Endotracheal Intubation Use history and physical exam to predict
a difficult airway Exam clues to the difficult airway
– Mouth opening test– Loose teeth– Mandible space (genu to thyroid
cartilage)– Presence of congenital abnormalities
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Preparation for Endotracheal Intubation Gather all necessities
– Needed personnel– Appropriate endotracheal tubes– Appropriate laryngoscope blades– Airway adjuncts ( stylets, oral airways etc.)– Suctioning equipment– BVM attached to oxygen at proper flow– Medications
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Miller Vs Macintosh
Miller (straight) blades are used to lift the epiglottis & expose the vocal cords– usually used in infants and small
children Macintosh (curved) blades are placed into
the vallecula lifting the base of the tongue which in turn lifts the epiglottis.– Used primarily in older children and
adults
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Miller and Macintosh Placement
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Procedure for intubation
Successful intubation involves a series of 6 separate maneuvers. – proper sedation (when required)– proper positioning (align the axis)– establishing a patent airway (BVM)– sweeping the tongue – visualization of the airway/cords– placement of the endotracheal tube
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Anatomic Landmarks
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Intubation faux pas
“Shoulder rolls” in children 2 or older Laryngoscopes held in the right hand Using the teeth as a fulcrum (tooth fairy) Passing the endotracheal tube down the
barrel of the laryngoscope Neck extension when spinal cord injury is
suspected Early release of cricoid pressure
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Post-intubation considerations
Bilateral breath sounds before tube secured and chest x-ray ordered
NGT in place for gastric decompression Tube migration into right mainstem or
esophagus Suctioning the tube following placement Ventilator settings provided
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Special Situations
Trauma patient in a C-collar Downs, Pierre-Robin and why can’t I see
the vocal cords Pulmonary Edema Laryngospasm Full Stomach