Respiratory Distress/Critical Airway
Deb Updegraff, RN, CCRNClinical Nurse SpecialistLPCH Pediatric Intensive Care Unit
Signs of Respiratory DistressSigns of Respiratory Distress
TachypneaTachypnea TachycardiaTachycardia Grunting Grunting StridorStridor Head bobbingHead bobbing FlaringFlaring Inability to lie Inability to lie
downdown AgitationAgitation
Continued- Signs and Symptoms of Respiratory Distress
•RetractionsRetractions• Use of AccessoryUse of Accessorymusclesmuscles•WheezingWheezing•SweatingSweating•Prolonged expirationProlonged expiration•Pulsus paradoxusPulsus paradoxus•ApneaApnea•CyanosisCyanosis
Causes of Resp DistressCauses of Resp Distress
InfectionsInfectionsPneumoniasPneumonias
BronchiolitisBronchiolitis
EmpyemasEmpyemas
Causes Cont.Causes Cont.
Excessive fluid in the lungExcessive fluid in the lungPulmonary edema (CHF)Pulmonary edema (CHF)
Excessive fluid or air in the pleural spaceExcessive fluid or air in the pleural spacePneumothorax, pleural effusionsPneumothorax, pleural effusions
Upper airway obstructionsUpper airway obstructionsswollen airway, large tonsils, malacias, swollen airway, large tonsils, malacias,
Lower airway obstructionsLower airway obstructionsasthmaasthma
InterventionsInterventions
Comfort measuresComfort measures Patient positionPatient position O2O2 DiureticsDiuretics Broncho-dialatorsBroncho-dialators Nasal trumpetNasal trumpet Positive PressurePositive Pressure Chest tubeChest tube IntubationIntubation
The Pediatric AirwayThe Pediatric Airway
IntroductionIntroduction Anatomy / PhysiologyAnatomy / Physiology PositioningPositioning AdjunctsAdjuncts IntubationIntubation
Anatomy : TongueAnatomy : Tongue
• LargeLarge• Loss of tone with sleep, sedation, CNS Loss of tone with sleep, sedation, CNS
dysfunctiondysfunction• Frequent cause of upper airway Frequent cause of upper airway
obstructionobstruction
Anatomy : LarynxAnatomy : Larynx• High positionHigh position
• Infant : C 1Infant : C 1• 6 months: C 36 months: C 3• Adult: C 5-6Adult: C 5-6
• Anterior positionAnterior position
Children Children areare different different
Photos : Calvin Kuan
Anatomy : EpiglottisAnatomy : Epiglottis
Relatively large size in childrenRelatively large size in children
Omega shapedOmega shapedFloppy – not much cartilageFloppy – not much cartilage
Airway PositioningAirway Positioning
““Sniffing Position”Sniffing Position”In the child older than 2 yearsIn the child older than 2 years
Towel is placed under the headTowel is placed under the head
Photos: Calvin Kuan
Photo: Calvin Kuan
Airway positioning for children Airway positioning for children <2yrs<2yrs
Photo: Calvin Kuan
Photo: Calvin Kuan
Airway adjunctsAirway adjuncts
Nasal airwayNasal airwayOral airwayOral airway
Adjuncts: Oral AirwayAdjuncts: Oral Airway
Correct sizeCorrect sizePhoto: Calvin Kuan
Nasopharyngeal AirwayNasopharyngeal Airway
Contraindications:Contraindications: Basilar skull Basilar skull
fracturefracture CSF leakCSF leak CoagulopathyCoagulopathy
Length: Nostril to TragusLength: Nostril to TragusLength: Nostril to TragusLength: Nostril to Tragus
Photo: Calvin Kuan
Endotracheal tube as nasal Endotracheal tube as nasal airwayairwayEndotracheal tube as nasal Endotracheal tube as nasal airwayairway
A regular A regular ETT can be ETT can be cut and used cut and used as a nasal as a nasal airway airway
Photo: Calvin Kuan
Intubation: IndicationsIntubation: Indications
Failure to oxygenateFailure to oxygenateFailure to remove COFailure to remove CO22
Increased WOBIncreased WOBNeuromuscular weaknessNeuromuscular weaknessCNS failureCNS failureCardiovascular failureCardiovascular failure
Laryngoscope BladesLaryngoscope Blades
Macintosh
MillerPhoto: Calvin Kuan
Intubation TechniqueIntubation Technique
Straight Laryngoscope Blade – used to Straight Laryngoscope Blade – used to pick up the epiglottispick up the epiglottis
Better in Better in younger children younger children with a floppy with a floppy epiglottisepiglottis
Photo: Calvin Kuan
Intubation TechniqueIntubation Technique
Curved Laryngoscope Blade – placed in the Curved Laryngoscope Blade – placed in the valleculavallecula
Better in Better in older children older children who have a who have a stiff epiglottisstiff epiglottis
Slide: Calvin Kuan
Anatomy : LarynxAnatomy : Larynx
Narrowest point = cricoid cartilage in the Narrowest point = cricoid cartilage in the childchild
Photo: Calvin Kuan
IntubationIntubation
AgeAge kgkg ETTETT Length (lip) Length (lip)
NewbornNewborn 3.53.5 3.53.5 993 mos3 mos 6.06.0 3.53.5 10101 yr1 yr 1010 4.04.0 11112 yrs2 yrs 1212 4.54.5 1212
Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12
Children > 2 years:Children > 2 years:ETT size: ETT size: Age/4 + 4Age/4 + 4ETT depth (lip): ETT depth (lip): Age/2 + 12Age/2 + 12
Slide: Calvin Kuan
Technique: IntubationTechnique: Intubation
How far How far does it go in does it go in ??
Photo: Calvin Kuan
An Airway is designated CRITICAL by any of the following Criteria
•Airway status post reconstruction surgery
•Difficult airway in the OR per anesthesia
•Patients with syndromes recognized with difficult airwaysMicrognathia- Pierre Robin, Treacher Collins
Cervical Spine abnormalitieS•Goldenhars, Klipper-Fiell
•Macroglossia•Beckwith-Wiedemann, Downs, Achondroplasia
•Soft tissue abnormalities•Submandiibular masses, epiglottis, hemangiiomas
Treacher Collins
Before Mandibular Distraction After Mandibular Distraction
Treacher Collins
HemangiomaHemangioma
Pierre Robin
Goldenhar
Subglottic stenosis is a narrowing of subglottic airway housed In the cricoid cartilage. This is the narrowest area in the pediatric airway.
Airway Reconstructive Surgery- Very Common Critical Airway patient in the PICU
Normal view of trachea
4 month old with acquired Grade III Subglottic stenosis from intubation
Same view: Magnified
Following Cricoid Split Surgical Procedure
Preoperative Subglottic View of 2 year old with acquired verticle subglottic stenosis
After anterior and posterior grafting and successful decannulation of tracheostomy
ICU Check list for Critical Airway:
Patient’s name:
Patient’s Weight:
-Room ready with intubation box.-Critical Airway sign posted at HOB.-Continuous infusion meds ordered (i.e. benzodiazepines, Opioids, muscle relaxants, and others).-Antibiotics and anti-reflux meds ordered.Sign-out has occurred and is documented.-ET tube is secured.-Chest x-ray obtained which is used to determine where the ET tube and CVL are located.
Patient to have arm restraints ordered and placed. Code Pack in the room.Code sheet completed in the room.My Doctor sheet completed and at the head of the bed.