airway emergencies sbh peds res儿科急症气道 sbh ped水库课件

Pediatric Airway Emergencies Elliot Melendez, MD Pediatric Emergency Medicine and Critical Care Childrens Hospital, Boston Disclosures No financial disclosures No conflict of interest Outline Discussion of stridor Challenges of pediatric airway Rapid assessment for difficult airway Critical airway management strategies Highest Acuity Patients Precipitating Conditions RespiratoryCirculatorySudden Cardiac Resp. Distress Respiratory failure Shock Cardiopulmonary Failure Cardiac Arrest Highest Acuity Patients Precipitating Conditions RespiratoryCirculatorySudden Cardiac Resp. Distress Respiratory failure Shock Cardiopulmonary Failure Cardiac Arrest Highest Acuity Patients Precipitating Conditions RespiratoryCirculatorySudden Cardiac Resp. Distress Respiratory failure Shock Cardiopulmonary Failure Cardiac Arrest Survival Data Survival rates for resuscitation from: Resp arrest: 43 82% Cardiac arrest 4 14 % Early recognition and treatment of respiratory compromise can improve outcome. Case 6 month boy p/w fever and cough x 5 days Cough is described as barky, and non-productive Normal behavior, not irritable, decreased pos Case VS: T 40.3, HR 150, RR 44, SaO2 95% on RA Chest: coarse breath sounds, but no wheezing. Inspiratory stridor at rest without increased work of breathing Remainder of exam unremarkable Case Decadron IM and racemic epinephrine neb were given with minimal improvement. While in ED, biphasic stridor at rest with severe retractions, becomes toxic appearing. Some mild improvement to repeat racemic epinephrine nebs Admitted to floor for observation Case Croup 6 mo to 6 years URI sxs Stridor +/- fever Could there be an alternative diagnosis? Stridor is the hallmark symptom associated with upper airway disease Rapid Assessment How Bad is it? If distress is severe Ie. stridor at rest, cyanosis, severe retractions, toxic appearing quickly examine and intervene If stridor is mild: Then obtain a more complete and accurate history develop a plan based on the differential diagnosis Stridor Croup Clinical diagnosis Routine radiographs of neck or chest not indicated Dexamethasone therapy of choice for airway edema If no stridor at rest, can send home Who do you need to work-up? Croup When stridor is atypical for croup: Fixed stridor or isolated exhalatory stridor. Poor/No response to inhaled racemic epinephrine and/or steroids Extremes of age Greater than age 6, less than 6 month Toxic appearing Persistently high fever. No viral prodrome, sudden onset Work-up Atypical Stridor Not all atypical stridor needs a work-up Admit and observe Physical Exam maneuvers Lateral and AP Neck CXR ENT consult Physical Exam Maneuvers Lay the infant Laryngomalacia worse with laying flat Pass nasal catheter to determine the patency Place in sniffing position and/or jaw thrust If the stridor lessens, obstruction may be at the level of the larynx or higher Atypical Stridor Heavy drooling High fever Refusing to move neck Retropharyngeal Abscess Typical presents 6-36 months Look at prevertebral space Complications include: Mediastinitis, pericarditis, airway obstruction Tip: Retropharyngeal swelling For C1-2 should be 50% Historical Factors Small jaws Congenital myopathies Pierre-Robin sequence, Crouzon Large tongues Beckwith-Weiderman syndrome Infiltrative d/os mucopolysaccharidosis Trisomy 21 Risk of malignant hyperthermia Duchenes MD 25% Noonans syndrome 50% Historical Factors Small jaws Congenital myopathies Pierre-Robin sequence, Crouzon Large tongues Beckwith-Weiderman syndrome Infiltrative d/os mucopolysaccharidosis Trisomy 21 Risk of malignant hyperthermia Duchenes MD 25% Noonans syndrome 50% Known/Suspect Difficult Airway Management Easy! Call for help The difficult pediatric airway is best NOT managed by heroic or uncommonly used techniques Carefully assess and plan Children with chronic/congenital issues has typically been intubated in past check anesthesia records if time permits Anticipate difficulties and prepare suitable back-up plan Call ahead, or know how to reach quickly, the anesthesiologists and surgeon on-call Case Scenario Called to transport full term newborn with respiratory distress Intubated at OSH with 3.0 uncuffed ETT On team arrival, poor chest movement on high vent settings and audible air leak Decision to change ETT to 3.5 uncuffed Clinical Decision Making Options: Sedate, muscle relax Increase vent settings Direct laryngoscopy for tube position Reintubate with larger tube, and/or cuffed tube Goals of Larynoscopy What we want to see is this Goals of Laryngoscopy The problem is but we are here. Cords are here Goals of Laryngoscopy The problem is The aim is To “see around the corner” The goal of DL To get rid of the corner To create straight line of sight Goal: Visualizing the Cords Aligning the 3 Axes Oral axis Pharyngeal axis Tracheal axis Oral Pharyngeal Tracheal Goal: Visualizing the Cords Aligning the 3 Axes Oral axis Pharyngeal axis Tracheal axis Case Course Under DL, visualized ETT through vocal cords, and removed. 3.5 uncuffed ETT passed easily through vocal cords Bag-ETT performed with no chest rise, and immediate desaturation Recurs x4 In between, easy bag-mask with chest rise Unrecognized Difficult Airway Management Are you able to mask ventilate and oxygenate? Difficult Intubation Interventions Upgrade intubator Bag mask until advanced airway interventions can be instituted Alternative modes Difficult Airway Difficult Mask Ventilation: inability to maintain SpO2 90% using 100% oxygen and BMV High risk Not only loss of airway, but risk of loss of vital signs Difficult Mask Difficult Mask after failed intubation Move quickly to alternative Immediate best intubator Immediate to alternative modes Fiberoptic, surgical airways time consumption Rarely done Technically difficult in peds Alternative: Laryngeal Mask Airway 1981 - Dr. Archie Brain Royal London Hospital Initially developed as a rescue tool Laryngeal Mask Airway LMA SizePatient Size 1Neonate / Infants 70 kg LMA: Insertion Figure 42-10 Insertion of the laryngeal mask airway (LMA). A, The tip of the cuff is pressed upward against the hard palate by the index finger while the middle finger opens the mouth. B, The LMA is pressed backward in a smooth movement. Notice that the nondominant hand is used to extend the head. C, The LMA is advanced until definite resistance is felt. D, Before the index finger is removed, the nondominant hand presses down on the LMA to prevent dislodgment during removal of the index finger. The cuff is subsequently inflated, and outward movement of the tube is often observed during this inflation. (Courtesy of LMA North America, Inc., San Diego, CA.) Mgmt