AIRWAY ASSESSMENT PAEDIATRICS PATIENTS LARYNGOSCOPY, INTUBATION

1. AIRWAY ASSESSMENT,
LARYNGOSCOPY AND
TRACHEAL INTUBATION IN
PAEDIATRIC PATIENTS
DR. ZIKRULLAH

2. • INTRODUCTION
• AIRWAY ASSESSMENT
• TECHNIQUE
• CONFIRMATON OF INTUBATION
• COMPLICATION
• SUMMARY

3. Introduction
• 80% of pediatric cardiopulmonary arrest
are primarily due to respiratory distress
• Majority of cardiopulmonary arrest occur
at <1 year old
• 1990 Closed Claim Project by ASA
– Respiratory events are the largest class of
injury (34%)
– More common in children than adults

4. Airway
Nasal &
oral cavity
Pharynx &
Larynx
Trachea &
bronchi

5. • DIFFERENCE BETWEEN PAEDIATRIC
AND ADULT UPPER AIRWAY ?

6. • Large head
• Large tongue in small oral cavity
• Mandibular angle 140*
• Narrow, floppy, relatively long and U-
shaped epiglottis

7. • Angled vocal cords
• More rostral Larynx at C3-C4
• Funneled shaped larynx-narrowest part of
pediatric airway is cricoid cartilage

8. Differently shaped epiglottis

9. Indications for endotracheal
intubation?

10. • Respiratory Distress
• Upper airway obstruction
• Shock or haemodynamic instability
• Neuromuscular weakness with progressive
respiratory compromise

11. • Inadequate respiratory drive
• Cardiac arrest
• General anaesthesia where a guaranteed
airway is needed

12. How do you assess airway in a child ?

13. • URI, Cough
• Snoring
• Day time somnolence
• Stridor
• Hoarse voice
• Apnoea
• Asthma
• Repeated pneumonias
• Previous anesthetic
problems
• H/O congenital
syndromes
Airway Evaluation
History

14. Physical Examination
• Evaluate shape and size of head , gross
features of the face.
• Size and symmetry of the mandible ,
presence of submandibular pathology.
• Size of tongue, shape of palate.
• Prominence of upper incisors.
• Range of motion of jaw, head and neck

15. • Retraction of suprasternal, intercostal or
subcostal regions indicate airway obstruction
• PRESENCE OF STRIDOR
– Inspiratory: Extrathoracic obstruction
– Expiratory: Intrathoracic obstruction
– Both: lesion at thoracic inlet

16. A simple and rapid way of assessing
airway in children developed by
LANE.
• COPUR SCALE ?

17. • COPUR:
• C- Chin
• Normal - 1
• Small, moderately hypoplastic - 2
• Markedly recessive - 3
• Extremely hypoplastic - 4
• O – Mouth opening
• >40 mm - 1
• 20 – 40 mm - 2
• 10 – 20 mm - 3
• <10 mm - 4

18. • P – Previous Intubation
– Easy previous attempt - 1
– No prev. attempt.no h/o OSA - 2
– OSA, prev. h/o diff. intubation - 3
– Unable to lie supine, h/o tracheostomy - 4
• U – Uvula
– Whole visible - 1
– Partially visible - 2
– Only soft palate visible - 3
– Soft palate not visible - 4

19. • R – Range of neck movement
– >120 - 1
– 60 – 120 - 2
– 30 – 60 - 3
– <30 - 4

20. • PREDICTION POINTS:
 5 – 7 : easy , normal intubation
 8 – 10 : laryngeal pressure may help
 12 : increased difficulty, fibreoptic may be
preferred
 14 : difficult intubation, fibreoptic/ other
advanced technique should be preferred
 16 : dangerous airway , awake intubation/
tracheostomy

21. • MALLAMPATI TEST ?

22. MALLAMPATI TEST
• Patient in sitting position
• Head in neutral position
• Maximal tongue protrusion
• No phonation
SAMSON-YOUNG’S MODIFICATION(1987)
Added Class IV and correlated b/w ability to
observe intraoral structures and incidence of
subsequent difficult intubations.

24. SIGNIFICANCE OF MMP SCORE
• Class III or IV: signifies that the angle
between the base of tongue and laryngeal
inlet is more acute and not conducive for
easy laryngoscopy

25. • Limitation of MMP scoring ?

26. • Hampered due to lack of co-operation
in small children.
• Does not accurately predict a poor
view of glottis during direct
laryngoscopy in pediatric patients

27. • Investigations to assess airway ?

28. DIAGNOSTIC TESTS
• Plain radiograph – for evaluation of
nasopharynx , pharynx , subglottic lesion and
trachea.
• CT and MRI scan : choanal atresia , neck and
mediastinal masses
• Direct or indirect endoscopy of the upper and
lower airway for functional assesment and
diagnosis of pathology.

29. • Fluoroscopy – for assesment of
dynamic pathology.
• USG studies - to assist in evaluation of
functional and organic airway
disorders, assess the dynamic state of
certain pathologies.

30. • What are the important predictors of difficult
tracheal intubation ?

31. • Hypoplastic mandible
• Limited mouth opening
• Facial asymmetry
• Obstructive sleep apnea syndrome
• Stridor
• Neck abnormalities
• Congenital syndromes

32. • How do you classify abnormal pediatric
airway ?

33. Classification of Abnormal Pediatric Airway
Congenital Neck Masses :
• Cystic teratomas, cystic hygroma,
neurofibroma, lymphoma, haemangioma
Congenital Anomalies :
• Choanal atresia, tracheoesophageal fistula,
tracheomalacia, laryngomalacia, laryngeal
stenosis, laryngeal web
Congenital Syndromes:
• Pierre Robin Syndrome, Treacher Collins, Turner,
Down’s, Goldenhar, Apert, Achondroplasia, Crouzan

34. Inflammatory:
• Acute tonsillitis,, laryngo-tracheo-bronchitis,
Adenoid hypertrophy, Juvenile rheumatoid
arthritis
Traumatic/Foreign Body :
• Burn, Inhalational injury, Post-intubation croup
(edema), Swelling of uvula
Metabolic :
• Congenital hypothyroidism,
Mucopolysaccharidosis, Glycogen storage disease

35. • Features of Pierre Robin syndrome ?

36. Pierre Robin syndrome
• Occurs in 1/ 8500 births
• Autosomal recessive
• Mandibular hypoplasia, micrognathia, cleft
palate, retraction of inferior dental arch,
glossoptosis

37. • Associated with OSA, otitis media,
hearing loss, speech defect, ocular
anomalies, cardiac defects,
musculoskeletal (syndactyly, club feet).

38. • Features of Treacher Collins Syndrome ?

39. Treacher Collins Syndrome
• Occurs in 1/10 000 births
• Mandibulofacial dysostosis
• Underdeveloped jaw causes tongue to be
positioned further back in throat (smaller
airway)

40. • Macrostomia
• Cleft or high arched palate
• Abnormal dentition
• External ear anomalies, unilateral absent
thumb
• A/w OSA, hearing loss, dry eyes.

41. • Features of Down’s Syndrome ?

42. Down’s Syndrome
• Trisomy 21
• Occurs in 1/660 births
• Short neck, microcephaly, small mouth with
large protruding tongue, irregular dentition,
flattened nose, and mental retardation

43. • Growth retardation, congenital heart
disease, subglottic stenosis,
tracheoesophageal fistula, duodenal atresia
• Atlanto-occipital dislocation can occur
during intubation due to congenital laxity of
ligaments

44. • What are the features of Goldenharr’s
syndrome ?

45. • Micrognathia
• Cleft palate
• U/L mandibular hypoplasia
• Klippel- Feil anomaly: short and
immobile neck

46. • How do you prepare for laryngoscopy and
intubation ?

47. Preparation prior to laryngoscopy
and intubation
• Airway assessment
• Checking airway equipments
• Preparing the patient psychologically and
by premedication
• Optimal position

48. • Proper height of operation table: at the level
of laryngoscopist’s navel
• Laryngoscopist to stand slightly away from
the patient to give a wider view
• Proper pre-oxygenation

49. • What is SOAPME ?

50. CHECKING AIRWAY
EQUIPMENTS
• Mnemonic SOAPME
• S: Suction (central, mobile)
• O: Oxygen
• A: Airway equipment (ETT, laryngoscope,
stylet, reservoir or self-inflating bag)
• P: Patient position
• M: Monitors
• E: Esophageal detection device, capnograph

51. • What is optimal position for laryngoscopy ?

52. Optimal Position
• No head elevation required in children less
than 8 years of age because of large head
which may cause unwanted head flexion
• Neutral position of neck ( i.e. no hyper-
extension of neck in neonate to be done
because it worsens visualization of glottis)

53. Miller vs. Macintosh blade ?

54. • Miller blade preferred for infants and
younger children
• Facilitates lifting of the floppy epiglottis
and exposing the glottic opening
• Macintosh blades generally used in older
children

55. Different sizes of blades ?

56. Based on Weight
Weight (kg) Blade size and type
0-3 Miller 0
3-5 Miller 0,1
5-12 Miller 1
12-20 Macintosh 2
20-30 Miller 2, Macintosh 2
>30 Miller 2 , Macintosh 3

57. Based on Age
Age Blade size and type
newborn Miller 0
1-12 months Miller 1
1-3 years Miller 2
3-12 years Miller 2, Macintosh 2
>12 years Miller 2, Macintosh 3

58. • How do you pre-medicate the Child?

59. • Atropine (0.02mg/kg) i.v/i.m
• Glycopyrrolate (0.01mg/kg) i.v/i.m
• Sedatives : under direct supervision.
• Midazolam: 0.03 mg/kg i.v,
• 0.3-0.5mg/kg P.O or i.m
• Ketamine : 4-6 mg/kg P.O or
2-4 mg/kg i.m or
0.5-1 mg/kg iv
• Fentanyl lollypop

60. • H2 blockers and/or Metoclopramide for
patients at risk of aspiration.
• Dexamethasone 0.1mg/kg iv

61. Preoxygenation
• Provides oxygen reservoir within lung often
needed by body tissue to tide over apneic
spell during intubation.
• 5min of 100 % oxygen via tight-fitting face
mask to replace predominant mixture of N2
contained in FRC of lungs

62. TECHNIQUE
• After proper preparation, Miller blade
laryngoscope is gently held in left hand at
junction of handle and blade.
• With right thumb and index finger open
patient’s mouth.
• Introduce laryngoscope blade from right
side of mouth opening without engaging lips
and teeth.

63. • As half of laryngoscope blade enters the
oral cavity, sweep tongue to the left
• Miller blade is then blade is passed so that
blade tip lies beneath laryngeal surface of
epiglottis.
• Epiglottis is then lifted to expose vocal cord.

64. • Then appropriate size ETT is picked up in
right hand and introduced into oral cavity
from right corner of mouth.
• Then ETT is passed through the vocal cords
till cuff of ETT disappears beyond vocal
cords.

65. • Note marking on the proximal end of ETT
in relation to patient’s incisor teeth.
• Inflate the cuff (if cuffed ETT) with air just
enough to withstand a sealing inflation
pressure of 20-30cm H2O.

66. • How do you choose the correct size
of ETT?

67. Size of ETT ID in mm
• For children 6 years and less:
• Age/3 + 3.5
• For children 7 years and above:
• Age/4 + 4.5
• ETT 0.5 mm larger and smaller than predicted
should be kept in airway cart.
• Outer diameter of ETT is that of little finger.

69. How to determine correct depth of insertion
of ETT ?

70. Depth of insertion of ETT
• For infants : 8 + (weight in kg)/2
• Over 1 year of Age: 13 + age/2
• 3 times of Internal diameter of ETT

71. Cuffed vs Uncuffed ETT ?

72. • Uncuffed ETT is used under the age of 8
years of age.
• Cricoid ring is the narrowest part of upper
airway and relative seal is obtained with
uncuffed ETT.
• Therefore uncuffed ETT which passes
cricoid area with a leak at 12-15 cmH2O
pressure is adequate.

73. • If cuffed ETT is used it may
be inadvertently exert tracheal
wall pressure exceeding
mucosal capillary perfusion
• On extubation ischaemic
area edema obstruction

74. • Other disadvantages with cuffed ETT :
• Smaller ID of ETT size compared to uncuffed
ETT of same external diameter increases
airway resistance and work of breathing
• Close monitoring to keep cuff pressure < 25 cm
H2O at all times.

75. • How do you confirm endotracheal
intubation?

76. Confirmation of tracheal intubation
• Primary confirmation:
Chest wall rise
Absence of gurgling sound over
epigastrium
Lung auscultation :
• Left and Right anterior
• Left and Right midaxillary
• Epigastrium

77. Secondary Confirmation
End-tidal CO2 detectors:
• Capnography
Miscellaneous techniques
• Chest and Neck X-ray
• SPO2

78. • Complications of endotracheal intubation ?

79. COMPLICATIONS
• Mechanical
• Respiratory
• Cardiovascular

80. Mechanical complications
• Trauma to lip, teeth or dental crown
• Oro-pharyngeal mucosal injury
• Dislocation of jaw
• Trauma to larynx
• Damage to vocal cords

81. Respiratory complications
• Laryngospasm
• Bronchospasm
• Subglottic stenosis
• Stridor, croup
• Aspiration +/- regurgitation
• Pneumonitis
• Pharyngitis and sore throat

82. Cardiovascular complications
• Bradycardia
• Hypotension
• Arrhythmia
• Hypoxia
• Hypercarbia

83. Summary
• Paediatric airway is not mini-adult airway.
• Little margin of error because of unique
airway anatomy and respiratory physiology.
• Keep calm; DON’T RUSH.

84. THANK YOU