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Respiratory Distress/Critical Airway

Respiratory Distress/Critical Airway. Deb Updegraff, RN, CCRN Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit. Signs of Respiratory Distress. Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation.

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Respiratory Distress/Critical Airway

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  1. Respiratory Distress/Critical Airway Deb Updegraff, RN, CCRN Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit

  2. Signs of Respiratory Distress • Tachypnea • Tachycardia • Grunting • Stridor • Head bobbing • Flaring • Inability to lie down • Agitation

  3. Continued- Signs and Symptoms of Respiratory Distress • Retractions • Use of Accessory muscles • Wheezing • Sweating • Prolonged expiration • Pulsus paradoxus • Apnea • Cyanosis

  4. Causes of Resp Distress • Infections Pneumonias Bronchiolitis Empyemas

  5. Causes Cont. • Excessive fluid in the lung Pulmonary edema (CHF) • Excessive fluid or air in the pleural space Pneumothorax, pleural effusions • Upper airway obstructions swollen airway, large tonsils, malacias, • Lower airway obstructions asthma

  6. Interventions • Comfort measures • Patient position • O2 • Diuretics • Broncho-dialators • Nasal trumpet • Positive Pressure • Chest tube • Intubation

  7. The Pediatric Airway • Introduction • Anatomy / Physiology • Positioning • Adjuncts • Intubation

  8. Anatomy : Tongue • Large • Loss of tone with sleep, sedation, CNS dysfunction • Frequent cause of upper airway obstruction

  9. Anatomy : Larynx • High position • Infant : C 1 • 6 months: C 3 • Adult: C 5-6 • Anterior position

  10. Children are different Photos : Calvin Kuan

  11. Anatomy : Epiglottis • Relatively large size in children • Omega shaped • Floppy – not much cartilage

  12. Airway Positioning “Sniffing Position” In the child older than 2 years Towel is placed under the head Photos: Calvin Kuan

  13. Photo: Calvin Kuan

  14. Airway positioning for children <2yrs Photo: Calvin Kuan

  15. Photo: Calvin Kuan

  16. Airway adjuncts • Nasal airway • Oral airway

  17. Adjuncts: Oral Airway Correct size Photo: Calvin Kuan

  18. Nasopharyngeal Airway Length: Nostril to Tragus Contraindications: • Basilar skull fracture • CSF leak • Coagulopathy Photo: Calvin Kuan

  19. Endotracheal tube as nasal airway A regular ETT can be cut and used as a nasal airway Photo: Calvin Kuan

  20. Intubation: Indications • Failure to oxygenate • Failure to remove CO2 • Increased WOB • Neuromuscular weakness • CNS failure • Cardiovascular failure

  21. Laryngoscope Blades Macintosh Miller Photo: Calvin Kuan

  22. Intubation Technique Better in younger children with a floppy epiglottis Straight Laryngoscope Blade – used to pick up the epiglottis Photo: Calvin Kuan

  23. Intubation Technique Better in older children who have a stiff epiglottis Curved Laryngoscope Blade – placed in the vallecula Slide: Calvin Kuan

  24. Anatomy : Larynx Narrowest point = cricoid cartilage in the child Photo: Calvin Kuan

  25. Intubation Age kg ETT Length (lip) Newborn 3.5 3.5 9 3 mos 6.0 3.5 10 1 yr 10 4.0 11 2 yrs 12 4.5 12 Children > 2 years: ETT size: Age/4 + 4 ETT depth (lip): Age/2 + 12 Slide: Calvin Kuan

  26. Technique: Intubation How far does it go in ? Photo: Calvin Kuan

  27. Critical Airway

  28. 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 airways • Micrognathia- Pierre Robin, Treacher Collins • Cervical Spine abnormalitieS • Goldenhars, Klipper-Fiell • Macroglossia • Beckwith-Wiedemann, Downs, Achondroplasia • Soft tissue abnormalities • Submandiibular masses, epiglottis, hemangiiomas

  29. Treacher Collins

  30. Treacher Collins After Mandibular Distraction Before Mandibular Distraction

  31. Hemangioma

  32. Pierre Robin

  33. Goldenhar

  34. Airway Reconstructive Surgery- Very Common Critical Airway patient in the PICU Subglottic stenosis is a narrowing of subglottic airway housed In the cricoid cartilage. This is the narrowest area in the pediatric airway.

  35. Normal view of trachea

  36. 4 month old with acquired Grade III Subglottic stenosis from intubation

  37. Same view: Magnified

  38. Following Cricoid Split Surgical Procedure

  39. Preoperative Subglottic View of 2 year old with acquired verticle subglottic stenosis

  40. After anterior and posterior grafting and successful decannulation of tracheostomy

  41. ICU Check list for Critical Airway: Patient’s Weight: Patient’s name: • -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 restraintsordered and placed. • Code Pack in the room. • Code sheet completed in the room. • My Doctor sheet completed and at the head of the bed.

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