(+)Marianne Gausche-Hill, MD, FACEP, FAAP

Professor of Clinical Medicine, David Geffen School

of Medicine at UCLA; Vice Chair and Chief of the
Division of Pediatric Emergency Medicine, Director
Pediatric Emergency Medicine and EMS Fellowships
Harbor-UCLA Medical Center, Department of
Emergency Medicine, Torrance, California; Chair,
2014 Advanced Pediatric Emergency Medicine
Assembly

Advanced Pediatric
Emergency Medicine Assembly
March 17-20, 2014
New York, NY
Pediatric Airway Management Update
The emergency physician can be challenged with GU
emergencies in pediatrics as they are not seen routinely.
What is normal for an infant, child, and adolescent?
What are some tips and tricks for examination? What
testing is imperative and do you need a consultant and, if
so, who? What are the most common and lifethreatening types of emergencies?

Review the most common and life threatening

GU emergencies by age category.
Discuss tips and tricks for the assessment and
examination.
Describe the assessment and testing needed
including consultant support.

Monday, March 17, 2014

MO-01
8:00 AM- 8:30 AM

(+)No significant financial relationships to disclose

Pediatric Airway Management

Update

Marianne Gausche-Hill, MD, FACEP, FAAP

Professor of Clinical Medicine and Pediatrics,
David Geffen School of Medicine at UCLA
Vice Chair and Chief of the Division of Pediatric Emergency Medicine
Director, EMS and Pediatric Emergency Medicine Fellowships
Harbor-UCLA Medical Center, Department of Emergency Medicine

Disclosures
None

Objectives
At the end of this session, you will be able to:
Describe clinical scenarios and the variety of airway
management approaches available.
Review current literature for cuffed and uncuffed
tubes, as well as a variety of different maneuvers to
better visualize the pediatric airway and high flow
nasal cannula during intubation.
Discuss the use of video laryngoscopy and its
potential impact on the visualization of the difficult
airway.

Whats New?

Cricoid pressure not recommended

Emphasis on bag-mask ventilation
Cuffed ET tubes preferred
Atropine in RSI algorithm to prevent bradycardia
is controversial/unlikely prevents
High flow nasal cannula to prevent hypoxia
during apneic period of RSI this is in!
Less etomidate more ketamine in RSI
Difficult airway video laryngoscopy and new
extraglottic devices

Case: 9 month-old boy

9 month-old boy brought in by paramedics
with a history of fever presents with
seizure at home
On arrival, patient has stopped seizing,
also has stopped breathing, and oxygen
saturation is dropping 90% - 86%- 80% 75%
What do you do now?

Where to Begin?

With the basics!

Move to more advanced procedures as needed
Standardize approach
Have contingency plan
Dont be afraid to call for airway experts

Airway Management Process

Position the head
Open the airway
If no air movement consider FB maneuvers/removal

Consider airway adjuncts to keep airway open

Oxygen if breathing and risk for hypoxia
Suction if secretions
Bag-mask ventilation if apnea or concern for
hypoventilation
If no chest rise consider FB maneuvers/removal

ETI [with RSI] high flow nasal cannula during apneic period
Difficult airway algorithm (e.g., Video laryngoscopy,
extraglottic devices or surgical airway)

Reassess quickly after each intervention

Position the head and open airway

Midline
Avoid excessive
flexion or extension
Towel under
shoulders or bump
under head to
achieve position
Jaw thrust VERY
useful in children in
relieving obstruction

Airway adjuncts
Oropharyngeal airway (OP)
May need in unconscious
patient to keep tongue from
occluding posterior pharynx
Cannot use in patients with an
intact gag reflex
Nasopharyngeal airway (NP)
Use in a semi conscious patient
to keep the airway open
Excellent for use in overdose
patients or seizure patients

Bag Mask Ventilation

Steps:
Size face mask
Choose bag [Adult,
Pediatric, Infant/Small
Child, Neonatal]
Attach bag to oxygen
EC-Clamp
Control rate and
volume delivered

Bag Mask Ventilation

BAG SIZE
Adult
800-1000 mL

Pediatric
450-500 mL

Small Child
290-400 mL

Neonatal
80-120 mL

Watch Out! Bag could be

too small

Bag Mask Ventilation

EC- Clamp
C holds mask
to face
E pulls chin
into mask
makes a clamp
3 fingers on the
jaw line
Doing BMV is as EC (easy) as 1-2-3

Bag Mask Ventilation

Hand placement:
EC clamp
Infants - avoid
pressure on
submental area
Only 1 finger
may fit on jaw
line

Bag Mask Ventilation

Too much cricoid
pressure may lead
to airway obstruction
If no chest rise with
BMV lighten
cricoid pressure
AHA 2010
Guidelines deemphasize use of
cricoid pressure

Bag Mask Ventilation

Control rate and
volume
Give only amount
of air needed to
get chest to rise
Say Squeeze (just until chest rise initiated) then
say release, release

Bag Mask Ventilation

Maximum ventilation rate:
Neonates - 40/min
Infants - 30/min
Children - 20/min
Slower rates are best too hard and too
fast will cause gastric distension

Endotracheal Intubation (ETI)

Preparation is key
Equipment and staff

Consider RSI as a
number of studies
have shown reduction
in complications with
its use
Have a contingency
plan if ETI fails

Endotracheal Intubation (ETI)

Equipment:

Suction
Oxygen
ET tube
Stylet (1 cm from
end of tube)
Laryngoscope with
appropriate blade
Pediatric Magill
forceps
CO2 detector

Calculation of ETT size - preemies

1 kg

Tube size
(mm)
2.5 mm

Depth of tube
(cm)
7 cm

3.0

3.0 - 3.5

Weight (kg)

Memorize this or put on a card no good rule

Calculation of ET tube size

Charts based on weight or length
Measurement from a length-based
resuscitation tape (Broselow Tape)
Greater than 1 year of age can
calculate tube size:
Based on age: (Age/4) + 4

Other methods:
Width of the child's little finger nail
Size of nare

10

Ballpark ETT size

Premature infant (2.5-3.0 mm tube)
Newborn 3.0-3.5 mm tube
Up to 6 months of age 3.5 mm tube
note should measure child with the lengthbased resuscitation tape - measure from top
of head to infant or child's heel

At one year of age need at least a 4.0 mm

tube

MGH Quick Method for

Uncuffed Tubes
1 yr

4 mm

10 kg

5 yrs

5 mm

20 kg

8-10 yrs

6 mm

30 kg

Extrapolate in between (e.g. 2 year old

=4.5mm ETT

11

Length-based resuscitation tape

Measure from head to heel of patient (3-36 kg)

Cuffed vs Uncuffed Tubes

Sizing:
less than standard formula (except for 3.0 mm)

When do you use a cuffed tube?

Any patient that may require high pressures to
ventilate
Can use it in any critically ill or injured infant or child
Studies show same frequency of subglottic stenosis
with cuffed tubes and less need for tube exchange

12

Laryngoscope Blade Size

Miller

Macintosh

Blade size
Miller 0 - premature infant or
small newborn
Miller 1 - normal newborn to
12 kg (2 years)
Miller 2 - 13 to 24 kg (7 years)
Miller 3 - 25 kg + (8 years +)

Miller 2
after age 2

Macintosh may be used

after 2 years of age
Too small a blade can get you into trouble

13

Depth of tube placement

Watch vocal cord marker go past
the cords
Depth of tube placement in cm
can be calculated as 3 X size of
tube:
(Example: 3.5 mm tube
would be placed at 10.5 cm at
the lip)
Depth can also be determined by
use of a length-based
resuscitation tape or by use of an
illuminated ETT

ET placement

14

Confirmation of tube placement

Clinical assessment
CO2 detection or monitor
Esophageal detection device (EDD)
Bulb or syringe
Chest radiograph
Pulse oximetry

ETT is too low

Complications post ETI

DOPE:
Dislodgement
Obstruction/Oxygen
Pneumothorax
Equipment fails

15

ETI: Lessons Learned

Place blade in just to the base of the tongue and
look for cords
If cant see anything but pink you are too far in back blade out a little bit or lighten cricoid pressure
If the blade is all the way in and you see the
epiglottis your blade is too small
If you see the epiglottis - advance blade a little
further
Get on you knees and look up its anterior

Foreign Body Aspiration

Begin with BLS maneuvers
Infant: Back blows (5) and
chest thrusts (5)
Child:
If conscious, abdominal
thrusts/Heimlich
Maneuver (5 per cycle)
If unconscious perform
chest compressions
ALS maneuvers if BLS fails
Use Magill forceps to
remove the foreign body

16

Rapid Sequence Intubation (RSI):

7 Steps

Preparation
Order and steps
dependent on clinical
Preoxygenation
situation
Pretreatment
Paralysis with induction
Protection and positioning
Placement of ET tube in trachea
Postintubation management

Preoxygenation
Add100%oxygen
Rememberinfantsbecomehypoxicquickly
relativelysmallreservoirinnasopharynx andlung
Nighmetabolicratevs adults

Highflownasalcannula(515Lpermin)can
preventhypoxiaduringapneicperiod

http://cagle.msnbc.com/news/FAT07/images/parker.gif

http://www.mhsks.org/assets/Infant.jpg

17

HFNC and RSI

Net pressure in the alveoli is subatmospheric
leading to apneic oxygenation
Achieving apneic oxygenation:
Use nasal cannula in the nonbreathing patient
the oxygen will fill the reservoir of the
nasopharynx
Children/Adults 15+L/min
Infants/Toddlers 5+L/min ????
\
Weingart SDandLevitan RM:AnnEmerg Med2011

Pretreatment
Atropine [0.02 mg/kg; min 0.1 mg; max 0.5 mg]
Pathophysiology
Paucity of sympathetic nerves to ventricles makes
them less electrically stable
Sympathetic-parasympathetic imbalance results in
accelerations and decelerations

Guidelines (APLS) - controversial

Use in infants < 1 year
Children 1-5 years who receive succinylcholine
Others who receive second dose of
succinylcholine

18

Bean A: EMJ/BMJ 2011

Reviewed literature on use of atropine to prevent
bradycardia in children during RSI
112 papers found 2 presented best evidence
Evidence from these two studies would indicate that
the incidence of reflex bradycardia in children during
rapid sequence intubation (RSI) is much lower than
previously thought.
Furthermore, it does not appear the paralysing agent
used significantly contributes to incidences of
bradycardia.
It appears that hypoxia, not foregoing pre-treatment
with atropine, is a stronger predictor of patients who
will develop reflex bradycardia following RSI.
Orjust have it available when you need it

Sedative Selection
Hypotension: Ketamine if concerned about
sepsis
Bronchoconstriction: Ketamine
Head injury without hypotension (or signs
of shock): Etomidate or thiopental or
midazolam
Head injury with hypotension: Etomidate
or ketamine

19

Neuromuscular Blocking Agents

Succinylcholine 2-3 mg/kg
ONLY depolarizing NMB: Binds to the Ach receptor
on the motor endplate and depolarizes the
postjunctional neuromuscular membrane
Onset 30-60
3-8 min
Do not under
dosesec,
in duration
childrencan
give 3 mg/kg
Shorter duration (plasma cholinesterase hydrolyzes), higher
in young risk
infants
[greater
of adverse
effects volume of distribution]

Rocuronium 1 mg/kg
Competitively block ACH transmission at the
postjunction cholinergic nicotinic receptor
Onset 1-3 min, duration 25-35 min
Longer duration, but less potential for adverse effects

Ventilator Management:
Ventilator settings are adjusted based on
patients clinical status
Chest rise, pulse oximetry, peak inspiratory
pressure, end tidal CO2 and blood gas
analysis
Selection of tidal volume based on the
following generally 6-8 mL/kg:
Visible chest excursion simulating normal
breathing
Audible air entry
Diminution of dyspnea

20

Case: 2 year-old boy

Mother rushes into triage with a 2 year-old boy
with a craniofacial abnormality
The child is obtunded with gasping respirations
and skin color is pale
The nurse calls for a physician and places the
child immediately in the resuscitation room
You attempt BMV but are unable to get a seal;
O2 sat is 70%; small jaw makes ETI impossible
What is your next airway option?

Management techniques:
Consider placement of OP or NP airway/ BMV
Supraglottic/Extraglottic airway - Laryngeal mask airway
(LMA), iGel, Air-Q, Laryngeal tube/King Airway
Intubate using other methods
Video laryngoscopy
Lighted stylet or Lightwand
Fiberoptic intubation

Other
Elastic Gum Bougie (not for kids- age 14 years+)
Combitube (not for kids age 14 yrs +)

Cricothyrotomy (needle children < 6 years?) if other

rescue devices fail and cannot BMV

21

Extraglottic/Supraglottic Devices
Air-Q able to intubate
through the device 3
studies in children
i-gel single-use with noninflatable cuff composed of
thermoplastic elastomer and
soft gel cuff has airway
tube and gastric tube [one study
in 50 children in OR good insertion rates
and few complication rates]

LMA Sizing on Broselow Tape

Sizing found on Broselow-Luten
Tape (2002 edition or greater)

LMA-Supreme

22

LMA Placement

King Laryngeal Airway

King systems
Laryngeal tube
(Noblesville, IN)

Supraglottic airway
device with a single
lumen
Passed blindly into the
esophagus
Available in 5 sizes
Can be used in children
>12 kg or 36 inches
Few data in children
http://www.kingsystems.com

23

Video Laryngoscopy
Routine or the difficult airway?
Why use it?
Offers expanded view
Magnified view enhances visualization
Can be performed with neutral neck position
Can be performed with reduced oral opening
Educational advantages share the view or
record attempt for teaching, performance
improvement

Video Laryngoscopy in Pediatrics

Device

Classification

Patient Size

Manufacturer/
Distributer

Airtraq

Channeled
device/optical
laryngoscope

Infant, child,
adolescent

Prodol/ King
Systems

Berci-Kaplan DCI
C-MAC

VL

Neonate, infant,
child, adolescent

Karl Storz
Endoscopy

Glidescope GVL,
Cobalt, Ranger

VL

Neonate, infant,
child, adolescent

Verathon Medical

McGrath Series 5

VL

Adolescent

Aircraft Medical/
LMA North America

Pentax AWS

VL, channeled
device

Adolescent

Pentax/ Ambu

Truview EVO2

Optical laryngocope
with video capability

Infant

Truphatek
International

Angulated VideoIntubation
laryngoscope

VL

Child, adolescent

Volpi
[Not available in US]

24

Video Laryngoscopy
Increasing use of video
laryngoscopy for routine
intubations
Still primarily used for the
difficult airway
Devices vary in cost and
portability
GlideScope most widely
used at this point but others
have advantages

Pediatric Airway Management

Airway management is a
process involving
assessment followed by
interventions followed by
reassessment begin with
basics
Children can be daunting
because of sizing
issueskeep tools available
to help!
Master basic and advanced
techniques

25

References

Holm-Knudsen RJ, Rasmussen LS. Pediatric Airway Management:

Basic Aspects. Acta Anaesthesiol Scand 2009;53:1-9.
Barata I. The Laryngeal Mask Airway: Prehospital and Emergency
Department Use. Emergency Medicine Clinical North America
2008;26:1069-1083.
Chen L, Hsiao AL. Randomized Trial of Endotracheal Tube Versus
Laryngeal Mask Airway in Simulated Prehospital Pediatric Arrest.
Pediatrics 2008;122:e294-297.
Duyndam A, et al: Invasive ventilation modes in children: A systematic
review and meta-analysis. Crit Care 2011;15:R24 epub ahead of print
Grein AJ, Weiner GM. Laryngeal Mask Airway versus Bag-mask
Ventilation or Endotracheal Intubation for Neonatal Resuscitation.
Cochrane Database System Rev 2005:18:CD003314.
Kerrey BT, Geis GL, Quinn AM, Hornung RW, Ruddy RM. A Prospective
Comparison of Diaphragmatic Ultrasound and Chest Radiography to
Determine Endotracheal Tube Position in a Pediatric Emergency
Department. Pediatrics 2009;123:e1039-1044.

References
RSI:
Bean A. Atropine: Re-evaluating its use during paediatric RSI.
Emerg Med J 2007;24:361-362.
Ching KY, Baum CR: Newer agents for rapid sequence
intubation Pediatr Emerg Care 2009;25:200-210.
Fastle R, Roback M: Pediatric Rapid Sequence Intubation:
Incidence of Reflex Bradycardia and Effects of Pretreatment
With Atropine. Pediatr Emerg Care 2004;20(10):651-655.
Lecky F, Bryden D, Little R, Tong N, Moulton C. Emergency
Intubation for Acutely Ill and Injured Patients. Cochrane
Database Syst Rev. 2008;16:CD001429.
Weingart SD: Preoxygenation, reoxygenation, and delayed
sequence intubation in the emergency department. J Emerg Med
2011;40(6):661-667.
Weingart SD, Levitan RM. Preoxygenation and prevention of
desaturation during emergency airway management. Ann Emerg
Med 2011; [EPub ahead of print]

26

References
RSI
Lemyre B, et al: Atropine, fentanyl and succinycholine for non-urgent
intubations in newborns. Arch Dis Chil Fetal Neonatal Ed 2009;94:F439F442.
Mace SE. Challenges and Advances in Intubation: Airway Evaluation
and Controversies with Intubation. Emerg Med Clin N Am 2008;26:9771000.
Nagler J, Bachur RG. Advanced Airway Management. Curr Opin
Pediatr 2009;21:299-305.
Waage NS, Baker S, Sedano HO. Pediatric Conditions Associated with
Compromised Airway: Part 1--congenital. Pediatr Dent 2009;31:236248.
Zuckerbraun NS, Pitetti RD, Herr SM, Roth KR, Gaines BA, et al. Use
of Etomidate as an Induction Agent for Rapid Sequence Intubation in a
Pediatric Emergency Department. Acad Emerg Med 2006;13:602-609.
Zelicof-Paul A, et al: Controversies inrapid sequence intubation in
chidlren. Curr Opin Pediatr 2005;17:355-362.

References
Cricoid Pressure
Brock-Utne JG: Is cricoid pressure necessary? Paediatric
Anesthesia 2002;12:1-4.
Butler J. Cricoid pressure in emergency rapid sequence
induction. Emerg Med J 2005;22:815-816.
Ellis DY, Harris T, Zideman D: Cricoid pressure in emergency
department rapid sequence intubations: A risk benefit analysis.
Ann Emerg Med 2007;6:653-663.
Engelhardt T, Strachan L, Johnston G. Aspiration and
regurgitation in paediatric anaesthesia. Paed Anaesth
2001;11:147-150.
Sellick BA. Cricoid pressure to prevent regurgitation of stomach
contents during induction of anesthesia. Lancet 1961;2:404-406.
Salem MR, Sellick BA, Elam JO. The historical background of
cricoid pressure in anesthesia and resuscitation. Anesth Analg
1974;53(2):230-2.

27

References:

Jaw thrust:

Bruppacher H, Reber A, Keller JP, Geiduschek J,

Erb TO, et al. The Effects of Common Airway
Maneuvers on Airway Pressure and Flow in
Children Undergoing Adenoidectomies.
International Anesthesia Research Society
2003;97:29-34.
Arai YC, Fukunaga K, Hirota S, Fujimoto S. The
Effects of Chin Lift and Jaw Thrust While in the
Lateral Position on Stridor Score in Anesthetized
Children with Adenotonsillar Hypertrophy.
International Anesthesia Research Society
2004;99:1638-1641.

References

Use of cuffed ET tubes in children:

Engelhardt T, Johnston G, Kumar M. Comparison

of Cuffed, Uncuffed Tracheal Tubes and Laryngeal
Mask Airways in Low Flow Pressure Controlled
Ventilation in Children. Pediatric Anesthesia
2006;16:140-143.
Ho A. Cuffed versus Uncuffed Pediatric
Endotracheal Tubes. Can J Anesth 2006;53:106111.
Newth C, Rachman B, Patel N, Hammer J. The
Use of Cuffed Versus Uncuffed Endotracheal Tubes
in Pediatric Intensive Care. The Journal of
Pediatrics 2004;144:333-337.

28

Video Laryngoscopy: References

Armstrong J, John J, Karsli. A comparison between the GlideScope Video

Laryngoscope and direct laryngoscope in pediatric patients with a difficult
airway. Anesthesia. 2010;65:353-7.
Cooper RM, Pacey JA, Bishop MJ, McCluskey SA, Early Clinical experience
with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anesth
2005; 52: 191-198
Hsu WT, Hsu SC, Lee YL, Huang JS, Chen CL. Penetrating injury of the
soft palate during GlideScope intubation. Anesth Analg 2007; 104: 16101611
Hurford DM, White MC. A comparison of the GlideScope and Karl Storz DCI
videolaryngoscopes in a paediatric manikin. Anaesthesia. 2010; 65:781-4.
Inal MT, Memis D, Kargi M, Oktay Z, Sut N: Comparison of TruView EVO2
with Miller laryngoscope in paediatric patients. Eur J Anaesthesiol 2010
Nov;27(11):950-4.
Kim JT, Na HS, Bae JY, Kim DW, Kim HS, Kim CS, Kim SD. GlideScope
video laryngoscope: A randomised clinical trial in 203 paediatric patients. Br
J Anaesth 2008;101:531-534.

Video Laryngoscopy: References

Karsli C, Der T. Tracheal intubation in older children with severe

retro/micrognathia using the GlideScope Cobalt Infant Video
Laryngoscope. Paediatr Anaesth. 2010; 20(6): 577-8.
Malik MA, ODonoghue C, Carney J, Maharaj CH, Harte BH, Laffey JG.
Comparison of the GlideScope, the Pentax AWS, and the Tru- view
EVO2 with the Macintosh laryngoscope in experienced anaesthetists: a
manikin study. Br J Anaesth. 2009; 102:128-134
Milne AD, Dower AM, Hackmann T. Airway management using the
pediatric GlideScope in a child with Goldenhar syndrome and atypical
plasma cholinesterase. Paediatr Anaesth. 2007; 17(5): 484-7.
Singh R, Singh P, Vajifdar H: A comparison of TRuview infant EVO2
laryngoscope with the Miller blade in neonates and infants. Peds
Anesthesia 2009;19(4):338-42.
Taub PJ, Silver L, Gooden CK. Use of the GlideScope for airway
management in patients with craniofacial anomalies. Plast Reconstr
Surg. 2008;121:237-8
White M, Weale N, Nolan J, Sale S, Bayley G. Comparison of the Cobalt
GlideScope video laryngoscope with conventional laryngoscopy in
simulated normal and difficult infant airway. Pediatric Anesthesia. 2009;
19:1108-12.

29

References
AHA
Kleinman ME, et al: Part 14: Pediatric Advanced Life Support:
2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation 2010;122:S876-2908.
Berg MD, et al: Part 13: Pediatric Basic Life Support: 2010
American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation
2010;122:S862-875.
Kattwinkel J, et al: Part 15: Neonatal resuscitation: 2010
American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation
2010;122:S909-919.

References

Resuscitation:

Kitamura T, et al: Conventional and chest-compression-only

CPR by bystanders for children who have out-of-hospital
arrests: A prospective, nationwide-population-based cohort
study. Lancet 2010;375:1347-1354.
Kleinman ME, et al: Pediatric Basic and Advanced Life
Support: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Pediatrics
2010;126;e1261-e1318.

30