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Diseases of the ear, nose and throat

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Diseases of the ear, nose and throat

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    1. Paediatric Stridor (airway compromise) Mr. Gerry Siou BSc.(Hons) MD FRCS(ORL-HNS) Consultant ENT Surgeon

    2. Paediatric life support for the non-breathing child SAFE approach ABC Airway manoeuvres Head tilt/chin lift Neutral (Infant) ‘Sniffing’ (child) Jaw thrust (care) Look, listen, feel 5 rescue breaths

    3. Securing the airway Oropharyngeal – Guedel Nasopharyngeal Endotracheal tube (>1year age) Internal diameter (mm) – (age/4) + 4 Oral ET length (cm) – (age/2) + 12 Nasal ET length (cm) – (age/2) + 15 Neonates – 2.5-3.5 mm internal diameter

    4. Acute Stridor Stridor Noisy breathing caused by partial obstruction of respiratory tract at or below larynx Stertor Noisy breathing caused by partial obstruction of respiratory tract above larynx

    5. History of ‘the noise’ Worse asleep ?Pharyngeal Worse with exertion ?larynx/trachea/brochial Inspiratory ?supraglottic Biphasic ?glottic/subglottic ?laryngotracheobronchitis

    6. Airway anatomical differences

    7. Clinical signs of airway compromise ? ? Resp rate +/- shallow resps Subcostal recession Intercostal recession Suprasternal tug Stridor (caution) Cyanosis Tiring/Agitation/confusion

    10. Why is the infant airway more at risk? Poiseuille's equation Resistance ? 1/r4 Flow ? r4

    11. Diagnosis & management

    12. Medical ‘First aid’ management Keep calm! (you, the child and everyone else) Parent and essential personnel only Anaesthetic team Nebulised adrenalin Dexamethasone Heliox

    13. Foreign body airway obstruction Infant Back blows Chest thrusts Child Back blows Heimlich

    14. Airway assessment What ‘kit’ do I need? Laryngoscopes Bronchoscopes Graspers Sucker Hopkins Rod Camera + Stack (Tracheostomy tray + Tubes)

    15. Paediatric laryngoscopes

    16. Ventilating bronchoscopes

    18. Optical graspers

    20. Airway assessment

    21. Supraglottic examples

    22. Glottic examples

    23. Laryngeal cleft grading

    24. Subglottic examples

    25. Mayer-Cotton Grading of subglottic stenosis

    26. Dynamic view

    27. Paediatric tracheostomy Old indications? Infective upper airway Current indications? Chronic obstruction/ventilation

    28. Surgeon’s perspective

    29. Exposure and technique Small skin incision Remove subcutaneous fat Vertical tracheotomy Maturation suture Stay sutures

    30. Maturation suture

    31. Tracheostomy tubes Shiley Neo Shiley Ped

    33. EXIT EX utero Intrapartum Treatment Pre-natal diagnosis Congenital laryngeal atresia Other upper aerodigestive or neck mass causing potential airway problems

    34. EXIT EX utero Intrapartum Treatment NOT a caesarian section Maximise uterine tone – prevent post-partum haemorrhage Minimize trans-placental diffusion of inhalation anaesthetic agents EXIT procedure Promote uterine hypotonia – maintain uteroplacental circulation Preserve uterine volume – prevent uterine abruption Deep maternal anaesthesia – normal maternal BP Adequate foetal anaesthesia – no cardiac depression

    35. EXIT EX utero Intrapartum Treatment Low transverse or midline incision – placental position Partial delivery of foetus (head, neck, shoulders) Umbilical cord attached Direct laryngoscopy + intubation Tracheostomy

    37. Thank you

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