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1、The Pediatric Airway 小儿气道,Anatomy and assessment of the pediatric airway Imaging of the pediatric airway The Management of difficult intubation in children,Anatomy,Nose The nose originates in the cranial ectoderm Composed of the external nose and the nasal cavity Into the nasopharynx via the choanae
2、 or posterior nasal apertures,Anatomy,Characteristic Soft and distensible, with relatively more mucosa and lymphoid tissue than in the adult Deviationof the nasal septum occurs in all ages of children easily obstructed by secretions, edema or blood,Anatomy,Paranasal sinuses ethmoidal, maxillary, fro
3、ntal and sphenoid sinuses airway obstruction caused by copious and tenacious secretions Cellulitis, edema or abscess formation may also occur.,Anatomy,Pharynx In free communication with the nasal cavity, the mouth and the larynx Nasopharynx、oropharynx 、 laryngopharynx,Anatomy,The nasopharynx of an i
4、nfant photographed with the 120 retrograde telescope.,Anatomy,The nasopharynx of a 5-year- old with mild congestion of the posterior end of the septum and the turbinates.,Anatomy,Oropharynx,Anatomy,Retropharyngeal abscess: a, abscess bulge; d,laryngoscope blade; b, uvula; c, tongue; e, tonsil,Anatom
5、y,Laryngopharynx,the piriform fossa,Anatomy,Laryngopharynx,The glottic and supraglottic structures in a 6-month-old infant.,Anatomy,Laryngopharynx,Laryngeal papillomatosis,Recurrent respiratory papillomatosis,(RRP),Anatomy,Laryngopharynx,Anatomy,Laryngopharynx,The presence of mucosal edema at this s
6、ite will severely compromise the airway,Anatomy,Anatomy,Laryngopharynx,Assessment of the pediatric airway,Imaging of the pediatric airway,Frontal chest radiograph in a 10-month-old infant. Normal expiratory tracheal buckling to the right (arrow) is demonstrated. Note the prominent right thymic sail
7、sign, also a normal variant.,Imaging of the pediatric airway,expiration (a),inspiration (b),Imaging of the pediatric airway,Two-year old with acute wheezing after eating peanuts,inspiratory radiograph (a),expiratory radiograph (b),Imaging of the pediatric airway,Lateral (a) Frontal (b) A double aort
8、ic arch vascular ring,Imaging of the pediatric airway,Sagittal ultrasonography,magnetic resonance imaging,Imaging of the pediatric airway,Goiter,Coronal (a) Sagittal(b) Fetal MRI T2 weighted,Imaging of the pediatric airway,Right bony choanal atresia.,The axial computerized tomography,Imaging of the
9、pediatric airway,CT and PETCT images a 12-yearold boy with Hodgkins lymphoma hypermetabolic palatine tonsils,Imaging of the pediatric airway,Tracheal agenesis with bilateral esophageal bronchi CT coronal minimum intensity projection imageconfirms an esophageal ETT,Imaging of the pediatric airway,Tra
10、cheomalacia,an 11-month male with noisy breathing demonstrates innominate artery compressing the trachea at the thoracic inlet,Imaging of the pediatric airway,Tracheomalacia resulting from external vascular compression,Imaging of the pediatric airway,Double aortic arch with tracheal narrowing,CT ang
11、iography with a volume rendered 3D image,coronal MPR (Multi-Planar Reformatted) image,Imaging of the pediatric airway,Bronchial foreign body,Fragments of peanuts were removed from the bronchus endoscopically,Imaging of the pediatric airway,Mediastinal lymphoma,Imaging of the pediatric airway,Lateral
12、 neck radiograph of a young toddler who presented with acute onset of hoarseness and stridor,The Management of difficult intubation in children,Issues must be discussed in detail with the parents! All discussions and plans should be clearly documented!,ASA Guidelines(2003),Difficult Airway Society g
13、uidelines Flow-chart 2004 (use with DAS guidelines paper),困难气道管理专家意见（2009）,Premedication,The individual circumstances of every case must be considered! Midazolam：0.30.5 mg kg-1 Oral Ketamine： 48 mg kg-1 Im 3-5 min Full monitoring applied is a priority！,Premedication,Antimuscarinics,Atropine,3040 g k
14、g-1 Oral 90min 20 g kg-1 IM 25min,Choice of anesthetic technique,Principle： Maintain spontaneous ventilation until the airway is secure！ Cant ventilate, Cant intubate scenario,Inhalational technique is favored in pediatric practice Use a gaseous induction with Sevoflurane in 100% oxygen An intraveno
15、us canula is placed Deepened to a plane where laryngoscopy can take place,Choice of anesthetic technique,Intravenous induction agent Preserve spontaneous respiration Propofol 0.51 mgkg-1 titrated slowly Ketamine 12 mgkg-1 again titrated Deepened with Sevoflurane An adequate plane of anesthesia has b
16、een achieved for laryngoscopy,Choice of anesthetic technique,Choice of anesthetic technique,Ephedrine and Lidocaine solutions attached to atomisers,Airway obstruct early Turned into the lateral position A soft nasal airway should be placed to clear the airway Improve the airway allowing the anesthet
17、ist to avoid oral airways till later in the induction,Choice of anesthetic technique,Polar north endotracheal tube (top) cut to length for use as a nasal airway (bottom),Choice of anesthetic technique,Golden rules : Have all equipment to hand and check before patient is in the anesthetic room Get go
18、od assistance, may be another experienced anesthetist Plan ahead, and have a bottom line plan a surgical airway,Choice of anesthetic technique,Macintosh laryngoscope the larynx cannot be viewed in an estimated 13% of cases,Equipment and techniques,Conventional rigid laryngoscopes: Tongue: size, obsc
19、ure the view, in the oral cavity Mandible: underdeveloped Larynx: a higher position A poor view with a curved rigid laryngoscope.,Equipment and techniques,Equipment and techniques,Miller blade advanced in the space between the tongue and the lateral pharyngeal wall or tonsillar fossa,Equipment and t
20、echniques,Macroglossia Micrognathia A straight blade laryngoscope should be first choice!,Equipment and techniques,Equipment and techniques,McCoy Macintosh blade for adult practice (sizes 3 & 4). Pediatric sizes on a Seward blade (sizes 1 & 2),Equipment and techniques,Equipment and techniques,Equipm
21、ent and techniques,Fiberoptic intubation,Equipment and techniques,Fiberoptic intubation Good oxygenation and deep anesthesia Topical anesthesia of the airway Planning and all necessary equipment Skilled assistance, plan and backup plan Equipment 、checked(cricithyroidotomy device and high pressure ve
22、ntilating device),Equipment and techniques,Fiberoptic intubation through a laryngeal mask airway,The unanticipated difficult intubation scenario,Soft tissue trauma and swelling Hypoxemic anesthetic deaths Brain damage Inadequate ventilation,The unanticipated difficult intubation scenario,89% could h
23、ave been prevented! Miller CG. ASA June 2000,The unanticipated difficult intubation scenario,Breathing spontaneously Clear airway Follow advice for a predicted difficult intubation Unanticipated difficult intubation does occur rarely,The unanticipated difficult intubation scenario,Difficult intubation scenario after paralysis Rapid Sequence Induction Made to awaken the child Maintain oxygenation and again Ventilation by the best means possible.,videos,Thank you ！,