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7/23/2019 En Pediatric Airway
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Gawat Darurat Pediatric
Powerpoint ® Presentasi Slide Pelajaran
Pediatric Emergency
Copyright @, Ns.MOHAMMAD ALI HAMID
7/23/2019 En Pediatric Airway
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ASA as! "orce o# Ma#age$e#t o%
the Di%%icu&t Airway ' De%i#itio#s( difficult airway ) the c&i#ica& situatio# i# which a co#*e#tio#a&&y
trai#ed a#esthesio&ogist e+perie#ces di%%icu&ty with $as! *e#ti&atio#,di%%icu&ty with trachea& i#tuatio#, or oth.
difficult mask ventilation ) -/ i#ai&ity o% u#assisted
a#esthesio&ogist to $ai#tai# SpO0 1 234 usi#g 334 o+yge# a#dpositi*e pressure $as! *e#ti&atio# i# a patie#t whose SpO0 was234 e%ore a#esthetic i#ter*e#tio#5 or -0/ i#ai&ity o% the u#assisteda#esthesio&ogist to pre*e#t or re*erse sig#s o% i#ade6uate*e#ti&atio# duri#g positi*e pressure $as! *e#ti&atio#.
difficult laryngoscopy ) #ot ei#g a&e to see a#y part o% the vocal
cords with co#*e#tio#a& &ary#goscopy
difficult intubation ) proper i#sertio# with co#*e#tio#a&&ary#goscopy re6uires either -/ $ore tha# three atte$pts or -0/$ore tha# te# $i#utes
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Pediatric PeriOperati*e Cardiac
Arrest -POCA/ 7egistry Co&&ects data %ro$ 89 &arge i#stitutio#s to
corre&ate perioperati*e pediatric deaths a#da#esthesia
he $a:ority are $edicatio# re&ated cardiacdeaths
22;'0339( 7espiratory e*e#ts i#creased %ro$03 perce#t to 0< perce#t.
he $ost co$$o# e*e#t &eadi#g to cardiac
arrest i# this category was &ary#gospas$,%o&&owed y airway ostructio#, i#ade6uateo+yge#atio#, i#ad*erte#t e+tuatio#, di%%icu&ti#tuatio# a#d ro#chospas$.
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Pediatric Airway =$erge#cies
I#%re6ue#t&y e#cou#teredStridor History a#d Physica& =+a$i#atio#Mu&tip&e =tio&ogies
Co#ge#ita& I#%&a$$atory Iatroge#ic Neop&astic rau$atic
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>rge#cy
Must assess the urge#cy o% the situatio#
"u&& a#d %ra#! discussio# o% the ris!s with
the pare#ts -a#d chi&d i% appropriate/
i#c&udi#g tracheosto$y a#d %ai&ure to
secure the airway
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A#ato$y
I#%a#t &ary#+('More superior i# #ec!'=pig&ottis shorter, a#g&ed
$ore o*er g&ottis'?oca& cords s&a#ted( a#terior
co$$issure $ore i#%erior ' ?oca& process 34 o% &e#gth
'Lary#+ co#e'shaped(
#arrowest at sug&ottic cricoid
ri#g
'So%ter, $ore p&ia&e( $ay e
ge#t&y %&e+ed or rotateda#terior&y
I#%a#t to#gue is &arger Head is #atura&&y %&e+ed
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History
Assess the urge#cy o% the situatio#
Si$u&ta#eous History a#d Physica& Cho!i#g Aggra*ati#g %actors
• "eedi#g, s&eepi#g, positio#i#g
hroat or #ec! pai# irth history
• Pre#ata&
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Sig#s o% i$pe#di#g respiratory %ai&ure I#creased respiratory rate
Nasa& %&ari#g >se o% accessory $usc&es Cya#osis
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Physica& =+a$i#atio#
Stridor Stertor
u&!y orophary#gea& #oise I#spiratory, e+piratory, or oth
Suprag&ottic I#spiratory
G&ottic I#spiratory progressi#g to iphasic
Sug&ottic I#spiratory progressi#g to iphasic
rachea& =+piratory
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"&e+i&e Lary#goscopy(
Proper =6uip$e#t
Assess
#aresBchoa#ae
Assess ade#oid a#d
&i#gua& to#si&
Assess ?C $oi&ity
Assess &ary#gea&
structures
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7adio&ogy(
P&ai# %i&$s( Chest a#d airway AP a#d
&atera&
=+piratory %i&$s
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Airway "&ouroscopy
uic!, #o#i#*asi*e, a#d dy#a$ic study Suprag&ottic( 994 G&ottic( <4 Sug&ottic( ;34 rachea&( <94 ro#chia&( ;34
"ar superior to p&ai# %i&$sDisad*( radiatio# e+posure
3 rads -3.Gy/ per $i#ute
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M7IBC
>sua&&y #ot use%u& i# a# acute setti#g
More re&ia&e %or e*a&uati#g #ec! $asses
a#d co#ge#ita& a#o$a&ies o% the &ower
airway a#d *ascu&ar syste$
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reat$e#t Optio#s
He&io+
Ora& Airways
I#tuatio# =#dotrachea& Lary#gea& Mas!
racheosto$y=I procedure
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He&io+
Graha$Es Law( %&ow rate
is i#*erse&y proportio#a&
to the s6uare root o% its
de#sity
He&iu$ <+ &ess de#se
tha# Nitroge#
Show# to e e%%ecti*e i#
upper airway ostructio#,
*ira& croup,poste+tuatio# stridor
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He&io+
GosF et a&( I$$ediate positi*e respo#se i# <94 o%
patie#ts A*erage duratio# o% treat$e#t $i# to 9;
hours -o*era&& $ea# o% 02.hrs/ Lary#gotracheoro#chitis were $ore &i!e&y to
respo#d tha# other causes. -other causeswere upper airway ostructio#, poste+tuatio#
stridor, co#ge#ita& heart disease/
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=#dotrachea& I#tuatio#
Mu&tice#ter study
8 out o% 0;; tota& =D i#tuatio#s 7apid Se6ue#ce I#tuatio# -;4/
ithout $edicatio#s -84/ Sedatio# without #euro$uscu&ar &oc!ade -84/
O*era&& success%u& i#tuatio#s 7SI 224 No# 7SI 2<4
O#&y out o% 8 re6uired surgica& i#ter*e#tio#
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7apid Se6ue#ce I#tuatio#
7eco$$e#ded %or e*ery e$erge#cyi#tuatio# i#*o&*i#g a chi&d with i#tactupper airway re%&e+es y the Pediatric
=$erge#cy Medici#e Co$$ittee o% the A$erica# Co&&ege o% =$erge#cyPhysicia#s
Si$u&ta#eous ad$i#istratio# o% a#euro$uscu&ar &oc!ade age#t a#d asedati*e
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I#tuatio#
7u&e o% Es( AgeB ) = siFe
Mucosa& i#:ury at 0c$ o% pressure. here%ore,a&ways chec! %or &ea!.
Spo#ta#eous *e#ti&atio#( a&&ows %or a &i$ited e+a$i#atio# o% the dy#a$ics o%*oca& cord $otio#.
Ap#eic tech#i6ue(
ur# to "iO0 334 prior to e+tuatio#. 8L O0B$i# %&ow *ia &ary#goscope Ge#era& ru&e to wor! ap#eic i# a proportio#a&
a$ou#t o% ti$e as reo+yge#atio#.
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Lary#gea& Mas! Airway
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racheoto$y
Cricothyroidoto$y is
di%%icu&t Bc o% s$a&&
$e$ra#e a#d %&e+ii&ity
=ar&y co$p&icatio#s P#eu$othora+, &eedi#g,
deca##u&atio#, ostructio#,
i#%ectio#s
Late co$p&icatio#s
Gra#u&o$a, deca##u&atio#,SGS, tracheocuta#eous
%istu&a
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=I Procedure
-e+ utero i#trapartu$ treat$e#t/ Pre#ata& diag#osis is
crucia& "&atte#ed diaphrag$s,
po&yhydra$#ios
he head, #ec!,thora+, a#d o#e ar$are de&i*ered.
>terop&ace#ta&circu&atio# ca# e$ai#tai#ed %or '83$i#utes
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Speci%ic =tio&ogies o% Airway
=$erge#ciesCo#ge#ita& Nec! Masses
Co#ge#ita& a#o$a&ies
Sy#dro$ic patie#ts I#%&a$$atory
"oreig# odies
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Co#ge#ita& Nec! Masses
Der$oid cysts Mesoder$Bectoder$
eratoid cysts a#d
terato$as A&& 9 &ayers 034 i#cide#ce o%
$ater#a&
po&yhydra$#ios
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Co#ge#ita& Nec! Masses
Ly$pha#gio$as
Capi&&ary, ca*er#ous,
cystic types
More airwayostructi*e whe#
%ou#d i# the a#terior
tria#g&e
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CHAOS-co#ge#ita& high airway ostructio# sy#dro$e/
=$erge#t airway $a#age$e#t at the ti$e o%de&i*ery is !ey %or sur*i*a&
Pre#ata&&y
"&atte#ed diaphrag$s, po&yhydra$#ios, cer*ica& $ass =AM Me$ers
Mater#a&'%eta& specia&ist Neo#ata&ogist
A#esthesio&ogist Oto&ary#go&ogist Patie#t
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Lary#gotracheoro#chitis
-Croup/ Parai#%&ue#Fa type
Ge#era&iFed $ucosa&
ede$a o% the &ary#+,
trachea, ro#chi
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Lary#gotracheoro#chitis
reat$e#tHu$idi%icatio#
No scie#ti%ic data to support May worse# the situatio#
7ace$ic =pi#ephri#e 7educes $ucosa& ede$aBro#chia& re&a+atio#
Steroids Syste$ic *s. I#ha&ed
I#tuatio#
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acteria& racheitis
Co$p&icatio# o% *ira&&ary#gotracheoro#ch
itis
"e*er, white cou#t,
respiratory distress%o&&owi#g a
co$p&icated course o%
croup
Staphy&ococcus
aureus
=#doscopy a#d
I#tuatio#
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Acute Suprag&ottitis
Mi&d >7I thatprogresses o*er a %ewhours to se*ere throatpai#, droo&i#g, a#d%e*er
H. i#%&ue#Fa,parai#%&ue#Fa
reat$e#t I#tuatio# =$piric A+
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Co#ge#ita& Sy#dro$es
C&ose e$ryo&ogica& de*e&op$e#t o% the
airways a#d the cra#io%acia& structures
=ar&y co$p&icatio#s are usua&&y $ore
pro%ou#d
Late co$p&icatio#s $ay e $ore sut&e
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Co#ge#ita& Sy#dro$es a#d Airway
=$erge#ciesSy#dro$es o% %acia& a#o$a&ies
Pierre 7oi# Se6ue#ce reacher Co&&i#s Go&de#harBHe$i%acia& $icroso$ia
De%or$ities o% s!u&& shape CrouFo#EsBApertEs P%ie%%er
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Pierre 7oi# Se6ue#ce
Microg#athia, re&ati*e$acrog&ossia with orwithout c&e%t pa&ate
I#tuatio# *ia the&atera& to#gueapproach
racheoto$y
G&ossope+y Superiostea& re&ease
o% $a#di&e
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reacher Co&&i#s
Hypop&astic chee!s,Fygo$atic arches, a#d$a#di&e5
Microtia with possi&eheari#g &oss5
High arched or c&e%t pa&ate5 Macrosto$ia -a#or$a&&y
&arge $outh/5 Co&oo$as5 I#creased a#terior %acia&
height5
Ma&occ&usio# -a#terior ope#ite/5 S$a&& ora& ca*ity a#d airway
with a #or$a&'siFed to#gue5
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Go&de#har J
He$i%acia& Microso$ia Ocu&oauricu&ar dysp&asia
Li$ited at&a#to'occipita& e+te#sio#
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K&ippe&'"ei&
Co#ge#tia& %usio# o%
a#y 0 o% the < cer*ica&
*erterae
Short, i$$oi&e #ec!
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CrouFo#EsB ApertEs
A#or$a& c&osure o% thecra#ia& sutures
Nasa& ca*ityNasophayr#gea&ste#osis' &eads to OSA
Associated a#o$a&ies SGS rachea& s&ee*es
reat$e#t Nasa& deco#gesta#tsB
ste#ts Se&ecti*e
ade#oidBto#si&&ecto$y racheosto$y Mid%ace ad*a#ce$e#t
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Mucopo&ysaccharidoses
Hu#terEs, Hur&erEs,
Marateau+'La$y
Progressi*e i#%i&tratio#
o% MPS withi# theairway structures
reat$e#t racheosto$y Death y age 3'
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Dow#Es Sy#dro$e
Mid%ace hypop&asia, $acrog&ossia, #arrow#asophary#+, a#d shorte#ed pa&ate.
I$$ature i$$u#e syste$
e#de#cy towards oesity G=7D is *ery pro$i#e#t =6ua&s a *ery di%%icu&t patie#t to sedate a#d sti&&
$ai#tai# a# airway
Lo#ger &i%espa# o% these patie#ts &eads to a#i#crease i# the i#cide#ce o% CH" a#d pu&$o#aryhyperte#sio# seco#dary to OSA
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Dow#Es Sy#dro$e
Mitche&& et a&. 09 Dow#s Patie#ts
;4 OSA 94 Lary#go$a&acia
Syste$ic co$oridities 84 G=7D
Cause o% >pper airway ostructio# is age re&ated 0yrs o&d( &ary#go$a&acia is $ost co$$o# cause
• Age depe#de#t progressio# to OSA 10yrs o&d( OSA is $ost co$$o# cause
• De&ay i# diag#osis is co$$o# ecause sy$pto$s o*er&ap
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Dow#Es Sy#dro$e
acos et a&. o% < patie#ts u#derwe#t upper airway surgery -a&& had DLB at
the sa$e ti$e/ JA with pi&&ar p&icatio#, >PPP
O*era&&(
<84 had sig#i%ica#t or co$p&ete re&ie% 04 had $oderate or se*ere residua& sy$pto$s "ai&ures(
Greater #u$er o% ostructi*e sites• Lary#gotrachea& ste#osis -094 o% %ai&ures/• o#gue ase
More se*ere >AO 7eco$$e#datio#s(
Co$prehe#si*e preoperati*e airway e*a&uatio# ai&or the surgica& procedure %or the site o% ostructio# C&ose %o&&ow up %or %ai&ures
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Choa#a& Atresia
"ai&ure o% the rea!dow#
o% the uccophary#ge&
$e$ra#e
McGo*er# Nipp&e a#d
#asogastric %eedi#g CHA7G= associatio#
Co&oo$as Heart a#or$a&ities
7e#a& a#o$a&ies Ge#ita& a#or$a&ities =ar a#or$a&ities
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"oreig# odies
0'year o&ds
Acute episode o% cho!i#gBgaggi#g
riad o% acute wheeFe, cough a#d
u#i&atera& di$i#ished sou#ds o#&y i# 34
'34 o% patie#ts $a#i%est #o o*ious
sig#s
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"oreig# odies
Se*erity is deter$i#ed y
co$p&ete *s partia&
ostructio#
Pea#uts are $ost
co$$o# 7ight $ai#ste$
Larger dia$eter More air%&ow tha# &e%t
Narrow a#g&e o% di*erge#ce Cari#a sits o# the &e%t side
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"oreig# odies
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"oreig# odies
P&ai# radiography( 04 o% ro#chia& &esio#s a#d 134 o%
trachea& &esio#s do #ot show up
Airway "&ouroscopy( Ao*e the cari#a( 90'34 e&ow the cari#a( ;3'234
DLB( Go&d Sta#dard
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Airway "oreig# odies
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