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(+)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


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


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


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


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


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


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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


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


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Hand placement:

EC clamp

Infants - avoid

pressure on

submental area

Only 1 finger

may fit on jaw

line


Too much cricoidpressure may leadto airway obstruction

If no chest rise withBMV lightencricoid pressure

AHA 2010Guidelines de-emphasize use ofcricoid pressure


9/31


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


Maximum ventilation rate:

Neonates - 40/min

Infants - 30/min

Children - 20/min

Slower rates are best too hard and toofast will cause gastric distension


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


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


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


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


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


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


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


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


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


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


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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


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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


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


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


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


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]


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


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]


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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.


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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.


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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.


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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.

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