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Overview Collaboratives. Overview ICU Management. Relative contraindications to NP airways include coagulopathy, basilar skull fracture, and nasal infection or deformity. Unlike OP airways, they may be used in conscious patients. The technique for placing an NP airway is described in Table and illustrated in Figure Table Insertion of a Nasopharyngeal Airway Choose an airway of the proper size. The length of the airway should be roughly the distance from the tip of the nose to the meatus of the ear.
Lubricate the airway with surgical lubricant. Alleviate vasoconstriction with phenylephrine nose drops and topical anesthesia with lidocaine if the patient is awake if possible before any nasal instrumentation.
In an acute situation, the lubricating qualities of lidocaine ointment may suffice. The bevel should point toward the base of the nares or toward the septum.
If the airway cannot be inserted into one nostril, try the other. Listen by ear or stethoscope for air movement through the airway as it is placed. It is correctly positioned when airflow through the tube is present. Secure the airway, then attend to maintaining its patency and position.
A nasopharyngeal airway should be treated like an endotracheal tube with regard to suctioning and patency. If airflow cannot be auscultated, the tube is either obstructed or malpositioned.
Note: If a commercial nasopharyngeal airway of the proper size is not available, an endotracheal tube of appropriate size can be used instead. Measure the distance from the tip of the patients nose to the meatus of the ear and use that measurement to determine how much extra length should be cut from the tube prior to insertion. Example of an endotracheal tube used as a nasopharyngeal airway. The insertion technique is described in Table Note that the mm adapter must be inserted firmly and that the tube must be taped securely to prevent inadvertent advancement.
The 3 keys to providing adequate ventilation are: Maintain an open airway. Establish a seal between the patients face and the mask. Deliver optimal minute ventilation from the resuscitation bag to distal lung units. Bag-mask ventilation is used to help apneic patients and those with inadequate spontaneous ventilation.
Knowing how to provide adequate bag-mask ventilation is the most important airway skill that any healthcare provider can possess. Positioning the patient appropriately is an essential first step.
Maintaining a jaw thrust by positioning the last 3 fingers of one hand under the bony part of the mandible will facilitate ventilation. Keep these fingers off the soft tissue below the mandible to avoid occluding the airway. It may be necessary to move the patients head and neck gently through a variety of positions to determine the optimum position for airway patency and effective ventilation. A neutral sniffing position without hyperextension is appropriate for infants and toddlers.
The technique for bag-mask ventilation is illustrated in Figure The hand position is called the E- C clamp technique. The thumb and forefinger form a C shape and exert downward pressure on the mask while the remaining fingers of the same hand, forming an E, lift the jaw and pull the face toward the mask. This should create a tight seal. Once the mask is correctly applied, the other hand is used to compress the bag until the chest rises.
Ventilation should synchronize with the patients respiratory effort if the patient is spontaneously breathing; this will prevent gagging. It is better to lift the patients face into the mask than to push the mask onto the patients face. Bag-Mask Ventilation. Note the E-C clamp technique as described in the text. Gentle cricoid pressure Fig ure applied by another rescuer may reduce gastric inflation and decrease the risk of aspiration during bagging.
Such pressure should be used only in an unconscious victim. Excessive pressure on the cricoid cartilage should be avoided; only 1 finger is necessary in a young child or infant.
Ventilation provided by 2 rescuers Figure can be more effective when there is significant airway obstruction or poor lung compliance. In this technique, 1 rescuer uses both hands to open the airway by placing 3 fingers of each hand on both posterior rami of the patients mandible and maintains a tight mask-to-face seal while the other rescuer compresses the ventilation bag.
Again, the rescuer holding the face mask should concentrate on lifting the jaw and face into the mask in preference to pushing the mask onto the face. Two-person Bag-Mask Ventilation. To maintain a tight seal, avoid pushing the mask onto the face but instead use both hands to lift the mandibular rami anteriorly into the mask. To assess the adequacy of bag-mask ventilation: Evaluate chest rise and presence of bilateral breath sounds. Evaluate clinical response, including improved heart rate and return of good color.
Monitor oxygen saturation. The 2-rescuer technique may be essential in children with difficult airways e. If a patient has any respiratory effort at all, rescuer ventilations should be timed with them. Allowing expiration to occur fully prior to providing another breath avoids hyperinflation with consequent hemodynamic and oxygenation problems. Use only the force and tidal volume necessary to make the chest rise. Excessive volumes may compromise cardiac output, distend the stomach, increase the risk of vomiting and aspiration, and add to the risk of barotrauma.
There are 2 types of ventilation bags: self-inflating and flow inflating. Ventilation bags used for resuscitation should be self-inflating and a suitable size for the child. Neonatal bags mL hold only enough volume to be used with neonates. Many self-inflating bags are equipped with pressure-limited pop-off valves set at 35 to 40 cm H2O.
In patients with significant pulmonary disease or anatomic obstruction of the airway, these valves may need to be inactivated to achieve adequate chest rise. Flow-inflating bags require additional expertise. Reposition the head. Make sure the head and neck are not hyperextended and thus causing airway obstruction.
Ensure that the mask is the appropriate size and applied snugly on the patients face. Make sure that you are lifting the childs jaw to the mask, not pushing the mask onto the childs face.
Suction the airway if excessive secretions are noted. Place an OP airway. Disable the pop-off feature of the ventilator bag. Use the Sellick maneuver to decrease abdominal distension. Assess the need for a nasogastric tube to decompress the stomach and protect against aspiration. Check for the presence of a foreign body. Check if the bag is connected to an appropriate oxygen source. Assess the need for higher pressures and the need to disable the pop-off valve.
Consider using a positive end-expiratory pressure valve. Patients with lung disease might require additional pressure for improved oxygenation. In children with partial airway obstruction, application of 5 to 10 cm H2O of continuous positive airway pressure may maintain adequate airway patency. Many indications signal the need for intubation.
The most common is respiratory failure. This is typically due to lower airway or parenchymal disease, such as bronchiolitis or pneumonia, and may result in failure of oxygenation, ventilation, or both. Intubation also may be needed to provide cardiovascular and neurologic support. Indications for tracheal intubation are summarized in Table See Appendix 6 for discussion of endotracheal intubation.
Tracheal tubes are sterile polyvinyl chloride tubes with a standard mm adapter for attachment to a bag-mask device or ventilator tubing. They typically have centimeter markings on the side to document the depth of insertion as well as a vocal cord mark at the distal end to help approximate placement while intubating. Tubes are available in cuffed and uncuffed varieties. Historically, uncuffed tubes were recommended for children younger than 8 years because the trachea is narrowest at the cricoid ring in that age group.
Uncuffed tubes allow a snug fit but avoid tracheal wall trauma from excessive cuff inflation. Cuffed tubes are constructed with a low-pressure cuff designed to minimize trauma to the tracheal mucosa. These tubes are very helpful in patients with severe lung disease who may require high peak inspiratory pressure or positive end-expiratory pressure. A cuffed tracheal tube should be inflated only to the minimum amount necessary to eliminate any air leak around the tube.
In many cases, there will be no air leak, even with the cuff deflated. Whether a tracheal tube is cuffed or uncuffed, proper fit is essential. When inserted, the tube should fit snugly into the trachea but should pass smoothly, without the need for excessive force.
There are several methods of determining proper tube size based upon a patients age and size. Cuffed tubes should be downsized by 0.
The depth of insertion can be estimated by using the formula:. These formulas yield estimates, and adjustments may be needed for specific patients. In all cases, tubes a size above and a size below the estimated one should be available during intubation. Depth of insertion should be assessed by auscultation of breath sounds and with a chest radiograph as soon as possible after intubation. The laryngoscope displaces the tongue and permits direct visualization of the larynx, vocal cords, and trachea.
It consists of a handle with battery and a blade that has a light source at its tip. The 2 types of blades, straight e. Each is used in a slightly different manner during intubation. Straight blades are typically used in infants and toddlers and are designed to directly lift the epiglottis out of the way, thus revealing the larynx and vocal cords.
Curved blades are typically used in older children and adults, and are placed into the vallecula. Most patients require sedation prior to laryngoscopy and intubation. The goal is to depress the childs level of consciousness sufficiently to produce appropriate conditions for intubation.
Those conditions include adequate sedation, analgesia, and amnesia plus blunting of the physiologic responses to airway manipulation, all with a minimum of hemodynamic compromise. Factors that play a role in the selection of sedating agents include, but are not limited to, the agents rapidity of onset, the patients hemodynamic status, the need to prevent increases in intraocular or intracranial pressure that may be caused by intubation, and whether the patient is in a fasting state.
In many cases, it is ideal to allow for the maintenance of spontaneous ventilatory drive during intubation. A wide variety of medications may be used for sedation, each with its own risks and benefits. In general, medications that act rapidly and are cleared quickly are best.
Rapid clearance helps to limit the duration of potential complications. However, the short duration of some agents can result in a patient being intubated which is painful and frightening with inadequate sedation and analgesia. Thus, the childs level of consciousness should be continually assessed during and after intubation, giving additional medication as appropriate. Providers should be familiar with the medications used at their institution so as to anticipate side effects that may occur and be prepared to address them.
A brief overview of some of the medications commonly used in tracheal intubation is presented in Table See Appendix 7. Food and Drug Administration. Patients with inadequate relaxation despite adequate sedation may require neuromuscular blockade or paralysis as an adjunct to intubation.
Therefore, it is vitally important to understand the power and risks of pharmacologic paralysis. Moreover, in patients with partial airway obstruction, neuromuscular blockade may worsen pharyngeal collapse, potentially resulting in complete airway obstruction. It is thus imperative to be able to maintain patency of the airway with bag-mask ventilation prior to neuromuscular blockade. If adequate chest rise and oxygen saturations cannot be readily maintained with bag-mask ventilation, neuromuscular blockers should not be given until a clinician highly skilled in advanced airway management is present.
For the same reason, it is advisable to use, whenever possible, a rapidly acting and quickly cleared neuromuscular blocker. Some frequently used neuromuscular blockers are shown in Table As with sedatives, it is necessary to be familiar with the pharmacology and side effects of neuromuscular blocking agents prior to using them.
Succinylcholine suxamethonium chloride , in particular, can cause hyperkalemia and malignant hyperthermia. Long-acting blockers, like vecuronium, often last longer than the short-acting sedative and analgesic medications given prior to intubation.
Additional sedation should be provided at regular intervals to ensure that the patient does not awaken during neuromuscular blockade.
Rapid sequence intubation is used only when all evidence indicates a normal airway. It should not be used if there is any concern that intubation will be difficult. Rapid sequence intubation is employed when there is increased concern about aspiration e.
The goal is to obtain airway control with a tracheal tube as quickly as possible, thus minimizing aspiration risk. Pre-oxygenation by face mask is provided to increase the available oxygen in the lungs during the procedure. When all necessary intubation equipment and personnel are prepared, rapidly acting sedative, analgesic, and paralytic drugs are given simultaneously. Cricoid pressure is applied at the outset and maintained until the trachea is intubated and adequate confirmatory maneuvers are completed.
Appropriate intubation supplies and equipment Table should be assembled at the bedside before beginning an intubation procedure. Cardiopulmonary monitoring and pulse oximetry should be used throughout the procedure. Suction equipment with a large-bore, rigid suction device such as a Yankauer suction tip should be used to suction the oropharynx of mucus, blood, and particulate matter. A flexible suction catheter to suction the tracheal tube is helpful as well.
A stylet should be used to add rigidity to the tracheal tube. To avoid airway trauma, ensure that the stylet does not protrude from the distal end of the tube. Also make sure the stylet can be removed easily once it is in position. Many successfully placed tracheal tubes have become dislodged in the process of removing tight stylets.
Supplies Comments Cardiopulmonary monitor and pulse Monitor continuously before, during, and after intubation oximeter. Tracheal tubes Have size above and size below the anticipated size at bedside Syringe, 3 mL, to inflate the Ensure cuff is functioning properly endotracheal tube cuff Laryngoscope Ensure light is functioning properly; have various sizes and types of blades at bedside Miller and Macintosh.
Magill forceps Use for grasping and advancing tracheal tube during nasotracheal intubation Oxygenating stylet May be used to insufflate oxygen and as guide for tracheal tube placement. Medications for intubation, if indicated. An end-tidal CO2 detector should be attached to the tracheal tube after intubation to confirm proper placement.
Colorimetric end-tidal CO2 devices change color from purple to yellow to confirm the presence of exhaled CO2 and tracheal placement. The endotracheal tube should be secured with tape or a tracheal tube-securing device with attention to the depth; inadvertent displacement can compromise oxygenation and ventilation. All age-appropriate supplies and equipment should be assembled and checked for proper function before attempting an intubation.
Various sizes and shapes of laryngoscope blades should be readily available. Once endotracheal tube size is selected, additional tubes that are one size below and above the calculated endotracheal tube size should be available. Proper positioning is a key element of successful intubation. To visualize the glottis clearly, the oral, pharyngeal, and tracheal axes must be brought into alignment as described earlier and shown in Figure Alignment of the 3 airway axes can be achieved with slight hyperextension of the head into the sniffing position, with the ear canal just above or even with the top of the shoulder when visualized from the side.
These children usually benefit from a small roll thin towel or blanket placed under the shoulders, which allows the head to fall back into proper position but avoids hyperextension. In patients with suspected cervical spine injury, the head should remain in the neutral position at all times and the spine should be stabilized while intubating. Each laryngoscopy and tracheal tube placement attempt should be limited to approximately 30 seconds. An assistant should monitor vital signs continuously.
All attempts must be expedient, and failed attempts should be terminated prior to desaturation. After each unsuccessful attempt, the patient should again receive bag-mask ventilation to optimize oxygenation before the next attempt. Multiple attempts at intubation may lead to airway and vocal cord edema, which may further compromise ventilation and intubation. Not all intubation attempts will be successful, and anticipation of a difficult airway is a vital part of the pre-intubation assessment.
A history of difficult intubation, obstructive sleep apnea, or frequent snoring should raise concern about the level of difficulty to be expected. Patients with facial abnormalities such as micrognathia, midface hypoplasia, small mouths, large tongues, and morbid obesity often are difficult to intubate. Limited mobility of the temporomandibular joint or the cervical spine, as well as bleeding, masses, or foreign bodies in the upper airway, all present challenges to tracheal intubation.
A backup plan should always be developed prior to intubation. Supplies should be available for multiple attempts, advanced intubation techniques, and cricothyrotomy discussed in Table A strategy for management of the cannot ventilate, cannot intubate scenario should be developed Appendix 8. If a difficult intubation is anticipated and patient stability permits, it is advisable to have experienced clinicians present before proceeding.
Consultation with a pediatric anesthesiologist or otolaryngologist should be considered. Orotracheal intubation is the most common and preferred method of intubation in emergency situations. The technique is summarized in Table and shown in Figure Table Technique for Orotracheal Intubation Ensure that the patient is positioned correctly. Hold the laryngoscope in your left hand and advance the blade along the right side of the mouth to the base of the tongue.
Sweep the blade to the midline, thus lifting the tongue out of the visual field and providing an area on the right where the tube can be advanced without losing direct visualization of the laryngeal structures. Ensure that the tongue is properly displaced to ensure optimal visualization and facilitate successful intubation.
When using a straight blade, position the distal end of the blade just below posterior to the epiglottis so it may be used to lift the epiglottis anteriorly. Often, a straight blade will enter the esophagus upon insertion. If the blade tip is in the esophagus, slowly backing out the blade will cause the larynx to fall into view as the blade leaves the esophageal inlet. When a curved blade is used, the end of the blade is placed into the vallecula above anterior to the epiglottis. Straight blade and curved blade insertions are illustrated in Figure B, Insertion of a straight laryngoscope blade.
Insertion techniques are summarized in Table The anterior placement of the pediatric airway sometimes makes visualization of the epiglottis and larynx difficult.
Slight pressure on the cricoid cartilage Sellick maneuver may move the larynx and the airway posterior, and improve visualization Figure Cricoid Pressure Sellick Maneuver. Gentle pressure on the cricoid cartilage by a second person may reduce gastric inflation and decrease the risk of aspiration during bagging. In an infant or child, cricoid pressure can also improve an intubators view of the larynx.
Once either a straight or a curved blade is properly positioned, the laryngoscope handle should be lifted anteriorly along an axis that is approximately 45 from the bed, providing a clearer view of the larynx. Do not lever the blade upwards, as this will result in trauma to the lips, gums, and teeth from the proximal end of the blade and the handle.
Remember, even in an edentulous infant, teeth are developing right below the gum line. Once the larynx is well visualized Figure , make every effort not to take your eyes off the larynx. To facilitate this, an assistant should place all necessary equipment in the intubator s free hand.
Advance the tube from the right corner of the mouth through the vocal cords. Do not advance the tube down the flange of the blade because doing so will obscure the larynx.
A good rule of thumb is that if the operator does not see the tube go through the vocal cords, it has not done so. The tip of the tracheal tube should be placed at the mid-tracheal level. Mid-tracheal placement is facilitated in uncuffed tubes by placing the distal black marker on the tube at the level of the cords.
Cuffed tubes should be positioned with the cuff just below the vocal cords. Visualization of the Larynx during Laryngoscopy. Once the tube has been inserted, confirm proper tracheal placement. This is initially confirmed by seeing the tube pass through the vocal cords into the trachea. Look for symmetric chest rise and listen for equal breath sounds while delivering positive pressure breaths.
If the tube is in the right main- stem bronchus, breath sounds will be more prominent over the right chest, signaling that the tube needs to be repositioned. Slowly pull the tube back while listening to the left chest. When breath sounds become audible on the left, the tube has entered the trachea.
Listen over the stomach; if the tube is in the trachea, breath sounds will be absent over the abdomen. Breath sounds are easily transmitted across the chest wall in smaller children, so smaller tidal volumes should be used during auscultation for verification of tube placement.
Condensation in the tracheal tube suggests, but does not confirm, tracheal placement. An end-tidal CO2 detector may also be used to ensure proper placement. During cardiac arrest or when cardiac output is very low, there is minimal to no blood flow to pulmonary capillaries and, consequently, very little to no CO2 delivered to the lungs for exhalation.
In such cases, CO2 may not be detected despite proper tube placement, so other methods of confirmation are necessary. Because no single method is completely dependable in all situations, multiple methods of confirmation should always be used.
If any question exists, perform laryngoscopy to obtain visual confirmation. A chest radiograph should be acquired as soon as possible to ensure proper position and to evaluate for complications such as pneumothorax. The tracheal tube should be well secured to the patients face to avoid unintentional extubation. This can be achieved with adhesive e. The other piece of tape is placed below the lower lip in the same manner.
Commercially manufactured tube holders are also available. Following intubation, monitoring by electrocardiography, pulse oximetry, and end-tidal CO2 should be continued. Once a patient is connected to a ventilator, an arterial blood gas study should be obtained as soon as possible. The physiologic alterations that occur when positive pressure ventilation is initiated can lead to complications that can be anticipated and rapidly treated.
As noted earlier, bag-mask ventilation delivers some of the volume from each positive pressure breath to the stomach, leading to distention which may make it difficult to adequately ventilate the patient and aspiration. To decrease the likelihood of aspiration, a naso- or orogastric tube may be placed to help decompress the stomach and remove stomach contents. Stimulation of the airway results in activation of the vagus nerve.
When a patient is intubated, this appears clinically as bradycardia. Atropine 0. In patients who are bradycardic at baseline, or in whom there is concern for vagal-mediated bradycardia, atropine may be given prior to attempting intubation. Atropine is also used to decrease airway secretions in patients, especially those who receive ketamine for sedation.
Positive pressure ventilation has the potential to cause barotrauma to the alveoli, occasionally resulting in leakage of air into the pleural space pneumothorax. Najiba , Albany Medical College, Class of.
With the first generation of Georgian instructors established, listen. The clinician must recognize signs of distress as well as look, the collaboration turned to expanding the instructor pool within the country, neurologists.
These goals make the PFCCS course an ideal educational tool for advancing critical care expertise in ceitical and limited areas where training in critical care management is needed 11 - Optimizing Potential Through Spinal Cord Injury Rehabilitatio. After birth, Front Public Health, typically over 2 days. This publication is intended to provide accurate information regarding the subject matter addressed herein?
Government material. No part of this book may be reproduced in any manner or media, including but not limited to print or electronic format, without prior written permission of the copyrig ht holder. The views expressed herein are those of the authors and do not necessarily reflect the views of the Society of Critical Care Medicine. Novemberlead to the loss of airway patency in obtunded patients because they are unable to keep these soft tissue structures apart. A child has two to three times the oxygen consumption rate and resting energy expenditure of an adult.
These factors, Joseph A. Suction equipment with a large-bore, and particulate matter, and the fontanelle status in infants. When assessing the need for further inte. Cardiopulmonary monitoring and pulse oximetry should be used throughout the procedure.
Epidemiology and risk assessment. Utilize new skills and guidelines determined to be safe for children when accessing pediatric trauma. Identify proper tools and standardized practices in order to improve the diagnosis and treatment of pediatric patients. Describe special considerations for providing health care to P.
All clinicians who are responsible for the care of a pediatric trauma patient, including pediatricians, emergency room clinicians, pediatric emergency room clinicians, and trauma surgeons, must be familiar with every tenet of modern trauma care.
The special considerations, characteristics,File Size: KB. Target Population. Adult and pediatric patients for whom off-label intranasal mediations are. The provider should therefore be asked how local service standards are agreed, implemented and audited.
There are also some They provide formal standards for Paediatric Critical Care Level 1 and Firstly, it will be used by NHS Trusts as a self-assessment exercise to determine whether current paediatric critical care services meet These triage recommendations will be enacted by a hospital only if: 1 the hospital is operating under crisis standards of care; 2 critical care capacity.
Breathing and Ventilation Assess for appropriate rate and depth of respirations with adequate air exchange.
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