Pediatric Airway Management
Jennifer Oliverio RRT, BSc
Clinical Educator
Respiratory Services
Alberta Children’s Hospital
A & P Characteristics of Newborn
Respiratory System
• Infant lung is a unique structure not a mini- adult lung
• Airways, distal lung tissue and pulmonary capillary bed
continue to grow and develop after birth
• General pattern is laid down at birth but upper and
lower airways continue to change
• Alveoli development complete and adult anatomy by 810 years of age
• Ossification of ribs and sternum complete by 25 years of
age
2
Nose
• Obligatory nasal breathing
• Poor tolerance to obstruction
Tongue
• Relatively Large
• Neck extension may not relieve obstruction
3
Head
• Relatively large
• Anterior flexion may cause airway obstruction
Epiglottis
• Relatively large and U- shaped
• More susceptible to trauma
• Forms more acute angle with vocal cords
4
Larynx
• More anterior and cephalad
• Intubation more difficult
Cricoid
• Narrowest portion of airway
• ↑ resistance with airway edema or infection
• Acts as “cuff” during tracheal intubation
5
Trachea
• Small diameter (6mm), high compliance
• ↑ resistance with airway edema or infection
• Collapses easily with neck hyperflexion or
hyperextension
Alveoli
• ↑ closing capacity
• No pores of Kohn
• ↑ air trapping and ↓ collateral circulation of air
6
Pulmonary Vessels
• ↑ pulmonary vascular resistance (PVR)
• Very sensitive to constriction by hypoxia, acidosis and
hypercarbia
Chest Wall
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•
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↑ compliance due to weak rib cage
↑ A-P diameter
Horizontal ribs
Breathing is all diaphragmatic
FRC determined solely by elastic recoil of lungs
Chest wall collapses with -ve pressures
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WOB
• Weak resp muscles
• ↑ RR = early sign of resp distress
Regulation of Breathing
• Response to ↓ O2/ ↑ CO2 minimal
• Tolerates hypoxia poorly
8
Airway assessment
• Best to 1st look from afar. Infants and small children
don’t like strangers hard to assess baseline after they
are upset.
• Is the chest moving?
• Can you hear breath sounds?
• Are there any abnormal airway sounds (e.g.. Stridor,
snoring)?
• Is there increased respiratory effort with retractions or
respiratory effort with no airway or breath sounds?
9
Airway Management
• Simple things to improve airway patency
• Suction nose and oropharynx
• Reposition child/ allow child to assume position of
comfort
• head-tilt-chin lift/ jaw thrust
• Use airway adjuncts- NPA/ OPA
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Oral & Nasopharyngeal Suctioning
• Clean technique
• Negative pressure of 80 to 120 mmHg. Test suction
level on regulator prior to suctioning
• Nasal and oral suction can be performed with same
catheter
• May result in hypoxia, ↓ HR (vagal), bronchospasm,
larygospasm, atelectasis
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Suction supplies
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Clean gloves
Suction regulator, canister, tubing
Normal saline in cup
Yankauer and appropriate suction catheter
Neonates
5-6 Fr
Infants
6-8 Fr
Older kids
10 Fr
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Nasopharyngeal Suction
• Measure length from pt’s earlobe to tip of nose
• Keep pass <10 sec.
• Document: pt assessment prior to procedure, time of
procedure, amount and type of secretions, pt’s response
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Positionning
•
If pt has preferred position let them remain in that
position e.g. tripod
• Repositioning can greatly improve airway patency
• Manual airway maneuvers can also help open the
airway (head tilt-chin lift/ jaw thrust)
14
Oral Pharyngeal Airways (OPA)
• Only for use in UNCONSCIOUS pt with no intact
cough/gag reflex
• Holds tongue and soft hypopharyngeal structures away
from posterior pharynx
• Still need good head and jaw position to maintain
airway patency
• Suction airway prn
• Never tape in place
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Choosing correct OPA
• Place OPA against side of face. With flange at the
corner of the mouth the tip should reach angle of the
jaw
• Too small: will not adequately displace tongue
• Too large: may obstruct larynx and/ or interfere
with mask fit if BVM required
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Nasopharyngeal Airways
• Soft plastic pre-made or shortened ETT
• Provides unobstructed path for airflow between nares
and pharynx
• Can use in conscious/ semi-conscious pt
• Small internal diameter so must be evaluated
frequently and suctioned prn to maintain patency
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If these don’t work…
• Pt may require more advanced interventions to
establish a patent airway
• CPAP
• Intubation
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Breathing
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RR
Effort
Tidal volume
Airway and lung sounds
SpO2
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RR
• Normals
As per PALS
Age
BPM
Infant (<1 yr)
30-60
Toddler (1-3)
24-40
Preschool (4-5)
22-34
School age (6-12)
18-30
Adolescent(13-18)
12-16
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RR
• Best to evaluate prior to hands-on assessment
• Excitement, anxiety, exercise, pain, fever, agitation can
all ↑ RR
• ↓ RR with acutely ill child or with ↓ LOC = ++ cause for
concern
• > 60 in any age is cause for concern
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Effort
• Signs of ↑’d respiratory Effort
– Nasal flaring
– Chest retractions
– Head bobbing
• Chin lifts and neck extends during I
• Chin falls forward during E
– Seesaw respirations
• Chest retracts and abdomen expands during I, reversed
during E
• Very Inefficient= quickly leads to fatigue
– Grunting
• Child exhales vs partially closed glottis in an effort to keep
small airways open
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Auscultation
• Same landmarking and principals as with adults
• BUT…smaller size and sound is transmitted much more
easily throughout the infant chest.
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Bag-Mask Ventilation
• Indicated when the pt’s spontaneous breathing effort is
inadequate despite patent airway
• Can provide adequate oxygenation and ventilation until
definitive airway control is obtained
• Can be as effective as ventilation through ETT
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**Multiple Mask sizes available so choose the correct one**
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Bagging Units
• 3 sizes:
Age
Volume (ml)
Infant
500
Child
1000
Adolescent
2000
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Testing the bagging unit
• Check all components before use to ensure proper
function. Ideally as part of your daily safety checks.
• Occlude pt outlet and outflow, squeeze bag ensure no
tears/leaks
• Check that PEEP valve works (2L)
• Ensure connection to wall O2 and adequate flow
• Proper size mask with cuff inflated
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Bagging
1.
Position pt: sniffing position
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Infants: Want
exterior ear
canal to be
anterior to the
shoulder
In our experience
at ACH we find a
shoulder roll
works best for
positioning infants
and small
children
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Bagging
1.
2.
Position pt: sniffing position
Open airway and seal mask to face using E-C
technique. You may need OPA.
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Bagging
1.
2.
3.
Position pt: sniffing position
Open airway and seal mask to face using E-C
technique. You may need OPA.
Squeeze bag with other hand to deliver tidal volume
and produce chest rise. Careful to not over-ventilate!
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2 person BMV
• One person uses both hands to open airway and
maintain tight mask-to-face seal
• 2nd person bags
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Monitor effectiveness of Ventilation
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Visible chest rise with each breath
SpO2
ETCO2
HR
BP
Pt responsiveness
Air entry on auscultation
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If ventilation is not effective…
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Reposition pt. Reposition airway. OPA.
Verify proper mask size and placement
Suction airway
Check O2 source and flow
Check bag and mask for function/leaks
Treat gastric inflation
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Indications for intubation
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Respiratory distress
Apnea
Self-extubation
Upper airway obstruction or the potential to develop
upper airway obstruction
• Actual or potential decrease in airway protection
(compromised neurological function)
• Need to eliminate/ reduce WOB (e.g. cardiac pt)
• Inadequate ventilation and/or oxygenation
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Preparing for Intubation
• Appropriate ETT for >1 yo: (age/4) + 4
Term infant: 3.0-3.5 ID
6 mo: 3.5-4.0 ID
1 yo: 4.0-4.5 ID
• Cuffed ETT’s for pt’s > 8 yo
• If you anticipate need for high PEEP or PIP may want to
use cuffed ETT with <8 yo. Use ½ size smaller ETT.
• Remember SOAPME
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SOAPME
Suction equipment: yaunkauer, catheters,
regulator/canister/tubing,
Oxygen: O2 flowmeter, preoxygenate 2-3 min, manual
resuscitator bag with mask
Airway equipment: ETT, stylet, syringe (cuffed ETT),
laryngoscope and blade, lubricating gel, OPA
Position, pharmacy, personnel: supine, rolls for
positioning, bed height up
Monitors
ETCO2 detector
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Post-Intubation
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ETCO2 assessment for confirmation of placement
Auscultation for bilateral air entry
Placement of ETT documented
ETT secured with tapes
CXR to confirm placement
Place pt on ventilator
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Acute deterioration post-intubation
• Remember DOPE
D
Displaced ETT
ETT may be in trachea or in right or
left mainstem bronchus
O
Obstruction of ETT
Secretions, blood, pus, foreign body,
kinked ETT
P
Pneumothorax
Simple
Tension
E
Equipment failure
Disconnection of O2 source, leak in
vent circuit, loss of power/ vent
malfunction
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Tube Position
• Remember: Endotracheal tube position follows chin
• Pt positioning ++ important. Often need shoulder roll to
keep chin neutral.
• CXR need to be done with neutral, midline head
position (RRT should be called)
– Chin low- tube low
– Chin high- tube high
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Uncuffed ETT’s
• May have issues with leak
• Better success with Pressure modes of ventilation with
a tube leak
• Position of pt can affect amount of leak
• If having difficulty with ventilation or oxygenation may
need to upsize ETT or Δ to cuffed ETT
• Short term fix: NS soaked nasal packing packed around
ETT. DO NOT CUT the gauze.
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Cuffed ETT
• Important to assess cuff inflation Qshift
• > 8 yo can follow adult VAP guidelines
• 25-30 cm H2O inflation pressure
• < 8 yo MOV with pressure < 20 cm H2O often quite a bit
lower than 20
• Cuff is circumferential in a growing airway!
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Suctioning ETT
• Suction frequency depends on ETT size and pt needs:
• 4.0 i.d. and smaller- a minimum of Q8H unless
•
otherwise ordered
• 4.5 i.d. and greater- prn or as ordered
• All pt’s need for suction should be assessed hourly
and prn Sterile suctioning
Suction depth should only be 0.5 cm past the end of ETT
• Determine suction depth by using suction guide or
match number on catheter to number on ETT and
advance 0.5 cm.
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Assessing need for suction
• Clinical assessment of pt will determine frequency of suctioning.
Many factors influence the need for suction including but not limited
to:
– ETT Size
– Changes in vital signs
– Adventitious breath sounds
– ↓ breath sounds/ chest movement
– ↓ SpO2
– Visible secretions in ETT
– Respiratory distress
– Coughing
– ↑TcCO2/ EtCO2
– ↑ PIP
– Worsening ABG/CBG
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Selecting suction catheter
• Use largest size that can pass easily down the ETT
• Ideally not larger than half the diameter of ETT to avoid
causing atelectasis
• TIP: choose double the ETT
e.g. 4.0 i.d. ETT choose 8 Fr suction
catheter
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Wall suction
Use lowest possible setting
Age
negative pressure
(mmHg)
< 1 yo
60-80
1-12 yo
80-120
13-17 yo
100-150
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Instillation
• Normal saline unless otherwise ordered
• Should occur prn not routinely
• For <10 FR you can use sterile NS syringe as there is no oneway valve in instillation port. For >12 Fr you will need pink NS
nebule.
• Recommended amounts:
Age
Volume
< 1 yo*
0.5-1.0 mL
1-12 yo
0.5-3.0 mL
13-18 yo
0.5-5.0 mL
*total volume is
especially
important to limit
and document in
infants and small
children
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Suction Guide
• Should be filled out at the bedside for all ETT < 4.5 and
all pediatric tracheostomy pt’s regardless of tube size
• Suction ½ cm farther than marked length to clear end of
ETT unless otherwise ordered (e.g. TEF repair)
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Closed Suction
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Patient Preparation
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Assess pt visually and auscultate, note monitor readings
Determine need for sedation/ analgesia
Ensure ETT tapes are secure
Explain procedure to pt/ parents
Pre- oxygenate and give meds as required
Position pt
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Closed Suction
• Ensure suction is on and set appropriately
• Ensure bagging unit attached to O2, adequate flow, and
intact
• Attach sterile syringe with appropriate instillation solution
to instillation port
• Securely hold ETT with one hand and insert catheter to
appropriate depth with the other
• Apply continuous suction while slowly withdrawing the
catheter
• Flush catheter by instilling into instillation port while
applying suction
• Allow pt to re-oxygenate at least 30 sec between passes
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Post-Suctioning
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Turn suction control to locked position
Remove instillation syringe and cap instillation port
Disconnect suction tubing and cap end
Reasess pt
Document:
– Time
– Initial assessment
– Amount of suctioning required
– Amount and type of secretions
– Amount and type of instillation
– Pt response
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