The Pediatric Airway小儿气道小儿气道Anatomy and assessment of the pediatric airwayImaging of the pediatric airwayThe Management of difficult intubation in childrenAnatomyNoseThe nose originates in the cranial ectoderm Composed of the external nose and the nasal cavityInto the nasopharynx via the choanae or posterior nasal aperturesAnatomyCharacteristicSoft and distensible, with relatively more mucosa and lymphoid tissue than in the adultDeviationof the nasal septum occurs in all ages of childreneasily obstructed by secretions, edema or bloodAnatomyParanasal sinusesethmoidal, maxillary, frontal and sphenoid sinusesairway obstruction caused by copious and tenacious secretionsCellulitis, edema or abscess formation may also occur.AnatomyPharynxIn free communication with the nasal cavity, the mouth and the larynxNasopharynx、oropharynx 、 laryngopharynxAnatomyThe nasopharynx of an infant photographedwith the 120 retrograde telescope. AnatomyThe nasopharynx of a 5-year- old with mildcongestion of the posterior end of the septum and the turbinates.AnatomyOropharynxAnatomyRetropharyngeal abscess: a, abscess bulge; d,laryngoscope blade;b, uvula; c, tongue; e, tonsilAnatomyLaryngopharynxthe piriform fossaAnatomyLaryngopharynx The glottic and supraglottic structures in a 6-month-old infant. AnatomyLaryngopharynx Laryngeal papillomatosisRecurrent respiratory papillomatosis (RRP)AnatomyLaryngopharynx AnatomyLaryngopharynx The presence of mucosal edema at this site will severely compromise the airwayAnatomy AnatomyLaryngopharynx Assessment of the pediatric airwaySleep studiesEndoscopyImagingInvestigationsExaminationHistory Imaging of the pediatric airwayFrontal chest radiograph in a 10-month-old infant. Normal expiratory tracheal buckling to the right (arrow) is demonstrated.Note the prominent right thymic sail sign, also a normal variant.Imaging of the pediatric airwayexpiration (a)inspiration (b)Imaging of the pediatric airwayTwo-year old with acute wheezing after eating peanutsinspiratory radiograph (a)expiratory radiograph (b)Imaging of the pediatric airwayLateral (a) Frontal (b) A double aortic arch vascular ringImaging of the pediatric airwaySagittal ultrasonographymagnetic resonance imagingImaging of the pediatric airwayGoiterCoronal (a) Sagittal(b) Fetal MRI T2 weightedImaging of the pediatric airwayRight bony choanal atresia.The axial computerized tomographyImaging of the pediatric airway CT and PETCT images a 12-yearold boy with Hodgkins lymphoma hypermetabolic palatine tonsilsImaging of the pediatric airway Tracheal agenesis with bilateral esophageal bronchi CT coronal minimum intensity projection imageconfirms an esophageal ETTImaging of the pediatric airway Tracheomalaciaan 11-month male with noisy breathing demonstrates innominateartery compressing the trachea at the thoracic inletImaging of the pediatric airwayTracheomalacia resulting from external vascular compressionImaging of the pediatric airway Double aortic arch with tracheal narrowingCT angiography with a volume rendered 3D imagecoronal MPR (Multi-Planar Reformatted) imageImaging of the pediatric airway Bronchial foreign bodyFragments of peanuts were removed from the bronchus endoscopicallyImaging of the pediatric airway Mediastinal lymphomaImaging of the pediatric airway Lateral neck radiograph of a young toddler who presented with acute onset of hoarseness and stridorThe Management of difficult intubation in childrenIssues must be discussed in detail with the parents!All discussions and plans should be clearly documented!ASAGuidelines(2003)Difficult Airway Society guidelines Flow-chart 2004 (use with DAS guidelines paper)困难气道管困难气道管理专家意见理专家意见（2009）PremedicationThe individual circumstances of every case must be considered!Midazolam：0.30.5 mg kg-1 OralKetamine： 48 mg kg-1 Im 3-5 min Full monitoring applied is a priority！Premedication Dry secretions Heart rateAntimuscarinicsAtropine3040 g kg-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 scenarioInhalational technique is favored in pediatric practiceUse a gaseous induction with Sevoflurane in 100% oxygenAn intravenous canula is placedDeepened to a plane where laryngoscopy can take placeChoice of anesthetic techniqueIntravenous induction agentPreserve spontaneous respirationPropofol 0.51 mgkg-1 titrated slowlyKetamine 12 mgkg-1 again titratedDeepened with SevofluraneAn adequate plane of anesthesia has been achieved for laryngoscopyChoice of anesthetic techniqueChoice of anesthetic techniqueEphedrine and Lidocaine solutions attached to atomisersAirway obstruct earlyTurned into the lateral positionA soft nasal airway should be placed to clear the airwayImprove the airway allowing the anesthetist to avoid oral airways till later in the inductionChoice of anesthetic techniquePolar north endotracheal tube (top) cut to length for use as a nasal airway (bottom)Choice of anesthetic techniqueGolden rules : Have all equipment to hand and check before patient is in the anesthetic roomGet good assistance, may be another experienced anesthetistPlan ahead, and have a bottom line plan a surgical airwayChoice of anesthetic techniqueMacintosh laryngoscope the larynx cannot be viewed in an estimated 13% of casesEquipment and techniquesConventional rigid laryngoscopes:Tongue: size, obscure the view, in the oral cavityMandible: underdevelopedLarynx: a higher position A poor view with a curved rigid laryngoscope.Equipment and techniquesEquipment and techniquesMiller blade advanced in the space between the tongue and the lateral pharyngeal wall or tonsillar fossaEquipment and techniquesu MacroglossiauMicrognathiaA straight blade laryngoscope should be first choice!Equipment and techniquesEquipment and techniquesMcCoyuMacintosh blade for adult practice (sizes 3 & 4).uPediatric sizes on a Seward blade (sizes 1 & 2)Equipment and techniquesEquipment and techniquesEquipment and techniquesFiberoptic intubationEquipment and techniquesFiberoptic intubationuGood oxygenation and deep anesthesiau Topical anesthesia of the airwayu Planning and all necessary equipmentuSkilled assistance, plan and backup planuEquipment 、checked(cricithyroidotomy device and high pressure ventilating device)Equipment and techniquesFiberoptic intubation through a laryngeal mask airwayThe unanticipated difficult intubation scenariouSoft tissue trauma and swellinguHypoxemic anesthetic deathsuBrain damageInadequate ventilationThe unanticipated difficult intubation scenario89% could have been prevented!Miller CG. ASA June 2000The unanticipated difficult intubation scenariouBreathing spontaneouslyuClear airway uFollow advice for a predicted difficult intubationUnanticipated difficult intubation does occur rarelyThe unanticipated difficult intubation scenarioDifficult intubation scenario after paralysisRapid Sequence InductionMade to awaken the childMaintain oxygenation and againVentilation by the best means possible.v videosideosThank you ！