ANAESTHETICS AND AIRWAY

ResponseWeight = (age + 4) x 2 (kg)

ResponseCUFFED = age/4 + 3.5
UNCUFFED = age/4 +4

ResponseETT Depth = Age / 2 + 12 - Best
ETT Depth = 3 x tube size

ResponseNarrowest part of paed airway subglottic.
Older paed ETTs had small volume, high pressure cuffs made of poorly tolerated materials leading to tracheal injury & subsequent subglottic stenosis.
Newer devices have larger volume, lower pressure cuffs and don’t tend to cause this

Response1 = infant (<6.5kg)
1.5 = <13 kg
2 = 6.5-25 kg
3 = >25 kg
4 = normal adult
5 = large adult
Say size up and down in answer

Response250 mL - Newborn and neonate only
500 mL - Neonates and infants
1500 mL - Neonates to adults

ResponseMiller (straight blade) Age <1
Macintosh
2=kids 3-12
3 = 12-16
4 = >16

ResponseLarger tongue
Larynx more cephalic (anterior and higher)
Increased compliance of chest wall
Larger head and occiput, Bulging occipital process (Flexed neck)
Smaller mandible
Narrowest part at cricoid cartilage
Epiglottis is logner and floppier
Smaller diameter at airway, therefore higher resistance to flow

ResponseSedation

• thiopentone need low dose eg 1mg/kg
• propofol similar eg 1mg/kg
• ketamine 1-2mg/kg
• can probably use other alternatives too

Paralysis

• sux then 1.5mg/kg is pretty standard
• roc then should give similar or slightly less

ResponseTV 6 mL/kg
RR ~20 (something sensibly normal for age)
FiO2 100% then titrate down

ResponseDisconnect and bag manually
Check tube position and suction tube
Bronchodilators
Assess for PTx and decompress if present
Positioning - sit more erect, consider prone. Lateral with R lung up
Advance tube beyond obstruction
Adequate PEEP to maintain patency
Change mode of ventilation - P/S rather than mandatory with ongoing paralysis
Anasethetic/ENT assistance - Bronchoscopy can identify levol of obstruction + mgmt
(? intubate dual lumen tube for L and R intubation)

ResponseSupraglotic - Expiratory stridor, sonorous, coarse, gurgling

• Foreign body, Down syndrome Choanal atresia

Glottic lesion - biphasic stridor

• Foreign body aspiration, Epiglotitis

Subglottic lesion - Inspiratory stridor, high pitched

• Subglottic stenosis, subglottic haemangioma, vascular ring, croup, bacterial tracheeitis, retropharyngeal abscess

ResponsePosition of child - sitting upright and forward means unstable airway when flat
Fever - infective cause - croup, retropharyngeal abscess
Toxic looking - Severe infection - bacterial tracheitis
Drooling - severe pain, unable to swallow due to obstruction
Muffled voice - supraglottic, epiglottis
Respiratory distress (RR, WOB, Hypoxia) - assess the effort and efficacy of breathing
Neck stiffness - infective cause, foreign body, trauma
Cyanosis, hypotonia, altered mental state - Severe respiratroy compromise with impending loss of airway
Character of noise

• Expiratory - supraglottic
• Biphasic - glottic
• Inspiratory - subglottic

ResponseAim to manage in theatre with anaesthetics and ENT present
Infant in position of comfort and parents close
Minimise distress, avoid IV/topical anasthetic/unnecessary transfer
Optomise medical management

• PO dexamethasone 0.3mg/kg (?RCH up to 0.6)
• Adrenaline neb 5mg
• HFNP 2L/kg
• IV access last minute

ED airway only if respiratory arrest
Check and prepare for direct + videolaryngoscopy
Anticipate difficult airway
Anticipate CICO and prepare for FONA
RSI drugs

• Ketamine 2mg/kg
• Roc 1.2mg/kg
• ETT + SIZE (probably have a size or two smaller ready)

Explanation to parents

ResponseExhaustion from increased WOB
Hypercapnoeic respiratory failure
Hypoxaemic respiratory failure
Decreased level of consciousness and unable to protect airway
Imminent complete airway obstruction