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Pediatric Airway
N/A
72
Nursing
Graduate
04/04/2016

Additional Nursing Flashcards

 


 

Cards

Term
Anatomic Differences Between Children and Adult Airways
Definition

Tongue

 

Position of Larynx

 

Epiglottis

 

Vocal Cords

 

Subglottis

 

Term
Tongue
Definition

Past knowledge thought tongue was large compared to oral cavity

 

Contribution of tongue to upper a/w obstruction actually minor

 

MAJORITY of obstruction d/t NASOPHARYNGEAL/EPIGLOTTIC collapse 

Term
Position of Larynx
Definition

Higher, more cephalad (Level C3-C4)

 

Hyoid bone (C2-3)...up to age 2

 

Tongue closer to larynx= difficult visualization of larynx

 

Straight blade better 

Term
Infant Epiglottis
Definition
Narrow, omega shaped, angled away from axis trachea
Term
Adult Epiglottis
Definition
Flat, broad and axis is parallel to the trachea
Term
Pediatric Epiglottis
Definition

Epiglottis axis angle with airway axis... more difficult to lift

 

stiff

 

Omega shaped, touch the soft palate (easy airway obstruction) 

Term
Vocal Cords
Definition

Cords are angled more anteriorly

 

Anterior insertion of cords is lower than posterior insertion 

Term
Subglottis
Definition

Functionally the narrowest portion of the larynx is the cricoid cartilage 

 

(Narrowest part for adults in cords) 

 

In children it is common to easily pass ETT through the vocal cords (glottic opening) but not through subglottic region 

Term
Subglottis Growth
Definition

Growth of the subglottis airway occurs rapidly during 1st 2 years

 

10-12 years cricoid and thyroid cartilages reach adult levels 

 

Angulation is then eliminated, narrow subglottic area resolved 

Term
Respiratory System Development
Definition

Begins during gestation week 4 

 

26-28 weeks gestation proliferation of the capillary network surrounding the terminal air spaces become sufficient for pulmonary gas exchange 

Term
Airway System Development
Definition
Bronchial tree bronchioles form by week 16 of gestation
Term
Alveoli Development
Definition
Develop after birth, increasing in # until 8 years old
Term
Type II Pneumocytes
Definition

Produce surfactant that forms the alveolar lining

 

Reduces surface tension and stabalizes air spaces after air breathing

 

Appear at 24-26 weeks 

Term
Transition to Air Breathing
Definition

Fetal breathing movements detected as early as 11 weeks

 

First Inspiration- critical event from placental and pulmonary gas exchange

 

First Gasp- generates transpulmonary pressure 40-80 mmHg

Term
Onset of Pulmonary Ventilation
Definition

Pulmonary blood flow sharply increases

 

Decrease in PVR and Increase SVR--> critical event immediate closure of foramen ovale

 

Reverse shunt through ductus arteriosus

 

HYPOXIA and ACIDOSIS= Increase PVR= R-L Shunt 

Term
Mechanisms of Breathing
Definition

Inspiration is entirely a result of diaphragmatic descent**

 

Diaphragmatic Fatigue: in preterm infants--> apnea

 

Diaphragm has very little type I (slow twitch, high oxidative) muscle fibers 

Term
Chest Wall in Neonates
Definition

Floppy, noncalcified cartilage, poorly developed musculature, noncalcified ribs, extend horizontally & move very little with inspiration 

 

Chest wall compliance decreases throughout childhood reflecting progressive calcification of the ribs 

Term
Lung Compliance
Definition
Volume is the principal factor that determines lung compliance, which increases throughout childhood
Term
Respiratory Variables
Definition

FRC= 80

 

TLC= 160

 

PaO2= Infants: 60-90, 1 year: 80-100

 

VC= 120 

 

Neonates greater dependent on diaphragm 

Term
FRC
Definition

When outward pull of chest= inward pull of lungs

 

Infants: end-expiratory volume> FRC

 

The infants chest wall more compliant, therefore, lung collapse not counterbalanced by chest wall rigidity 

 

Inspiratory muscles brake expiration impaired with GA--> tendency to develop atelectesis at regular TV 

Term
Tracheal Compliance
Definition

In neonates is 2x that of adults d/t cartilage immaturity

 

B/c of this dynamic collapse of trachea may occur on inspiration and expiration

 

A greater inspiratory force sucks in the floppy airway and decreases airway diameter---> increases work of breathing

Term
Air Dynamics
Definition

Chest wall highly compliant, ribs provide little support for lungs

 

Negative intrathoracic pressure poorly maintained

 

Function airway closure with each breath

 

Atelectesis develops rapidly 

Term
Regulation of Breathing
Definition

PaO2 act on peripheral chemoreceptors in carotids and aorta

 

PaCo2 act on central chemoreceptors

 

Infants respond to increase PaCo2 NOT potentiated by hypoxia

 

Hypoxia may depress the hypercapnia ventilator response 

Term
Neonatal Regulation of Breathing
Definition

up to 1 week full term

 

High FiO2 concentrations DEPRESS respiratios

 

Low FiO2 concentrations STIMULATE respirations...BUT not sustained...eventually ventilatory depression occurs 

Term
Obligate Nasal Breathing
Definition

Infants are obligate nose breathers 

 

Obstruction of the nares can cause asphyxia

 

Immature coordination b/w resp efforts & motor & sensory inputs

 

3-5 months can coordinate resp & oral function--> larynx enlarges and moves down---> cervical spine lengthens 

Term
Work of Breathing
Definition

O2 consumption in infant= 4-6 ml/kg/min

 

Greater O2 consumption= increased resp frequency

(greater metabolic demand)

 

 

Term
Infant Airway Resistance
Definition

Bronchiole and small airways 

 

Adults- nasal passages 60%

Term
Airway Resistance Overall
Definition

In infants the small diameter of bronchioles and very compliant chest wall results in less support to maintain NEGATIVE intrathoracic pressure 

 

means

 

Functional airway closure with every breath 



Small- airway resistance accounts for most of the work of breathing *** 

Term
Pre-Op Asthma
Definition

Affects 6 million children in the US

 

Hx Wheezing= Increased perioperative bronchospasm risk

 

Establish severity and control of asthma pre-op

 

Severe but well-controled vs mild but poorly controlled

Term
Severity and Control of Asthma
Definition

Frequency and control of symptoms

 

Limitation of effort tolerance

 

Night awakenings

 

Medication use

 

***ER Department Admit***

 

Hospitalizations

 

Ventilation Support 

Term
Asthma
Definition

Children should continue regular medications

 

Consider B-Agonist inhaler before or after induction to prevent airway resistance after trachel intubation

 

Consider ketamine/propofol

 

NO DES

Term
Bronchospasm
Definition

Deepen Anesthesia

 

Increase FiO2

 

Decrease PEEP

 

Increase expiratory time

 

Inhaler 

Term
Cystic Fibrosis
Definition

Lung disease is main morbidity

 

Malnutrition is common problem

 

Commonly anesthetize for ENT procedures d/t chronic sinus problems 

Term
Clinical Evaluation of Airway
Definition

Prescence of URI

 

Snoring or Noisy Breathing

 

Croupy cough= subglottic stenosis

 

Inspiratory stridor?

 

History of Congential syndrome?

 

Baseline O2 saturation of room air?

 

Global Appearance

Term
Mask Ventilation
Definition

Appropraitely sized mask should sit on the bridge of the nose and extend to the mandible

 

Most common error: compressing submental trainagle with fingers, partialy occluding the airway

 

Keep mouth opend to not obstruct a/w

 

Hand on reservior bag at all times

Term
Oral Airways
Definition

Have one size larger and one size smaller than needed 

 

Tip of airway should end just cephalad to the angle of the mandible 

 

Use tongue depressor 

 

Term
Oral Airway Complications
Definition

Should not be used as a bite block in children between 5 and 10 years of age with loose decidious teeth

 

Responsible for 55% of anesthesia- related dental complications

 

Bite blocks in long cases may cause necrosis of the tongue, uvular edema, or lip damage 

Term
Nasal Airways
Definition

Tolerated in the lightly anesthetized child better than an oral a/w

 

Careful with hypertrophied adenoid and tonsils 

Term
Position of Children
Definition

Large occiput of the infant provide natural neck flexion

 

Head extension aligns the oral, phayrnx, and tracha axes

 

> 6 years= sniffing 

Term
Blades
Definition
Infants and young children---> stright blade better to elevate base of tongue
Term
Preterm ETT size
Definition

3.0 uncuffed

 

3.0-3.5 cuffed 

Term
Neonate- 6 mo ETT Size
Definition
3.0-3.5 uncuffed & cuffed
Term
6 mo to 1 year ETT Size
Definition

3.5-4 uncuffed

 

3.0-4.0 cuffed 

Term
1-2 years ETT Size
Definition

4.0-5.0 uncuffed

 

3.5-4.5 cuffed 

Term
> 2 years ETT Size
Definition

Uncuffed= (Age +16)/4

 

Cuffed= (Age /40 +3 

Term
ETT
Definition

Always have .5 greater and less than the anticipated size available

 

Leak shoud be 20-25 mmHg

 

Short term leak can be as high as 35 mmHg

 

If no leak---> .05 mm ETT smaller

 

Leak prevent tracheal mucosal damage

Term
Reason Why Cuffed Tubes are Better
Definition

Less laryngoscopies

 

Decreased risk of aspiration

 

Accurate control of PCO2

 

Reduced use of anesthetic agents

 

No difference in post-extubation croup 

Term
Drawback to Cuffed Tubes
Definition

Variability in outer diameter b/c of differences in chuff shape and size

 

Use 0.5 size smaller if using cuffed tube

 

 

Term
Micro Cuff Tube
Definition

High volume/ low-pressure cuff 

 

more distal cuff 

Term

ETT Depth 

 

Up to 1 year old 

Definition

5-9 cm 

 

(easy to remeber 10 cm)

Term
ETT Depth
Definition
Term

ETT Depth 

 

1 year old 

Definition
11 cm
Term

ETT Tube 

 

2 year old 

Definition
12 cm
Term

ETT Depth 

 

> 2 years old 

Definition

Age/2 + 12

 

ID of ETT x 3

 

(weight in kg/5 + 12)

Term
After ETT is Inserted
Definition

Observe for chest symmetry of expansion

 

Auscultate in axilla & apices (chest wall)

 

Reconfirm after positioning

Term
Endobronchial intubation
Definition

increased a/w pressures 

 

desaturation

 

asymmetrical chest wall movement 

Term
Postintubation Croup
Definition

Increased risk with ETT with an OD too large, duration of surgery greater than 1 hours, traumatic intubation, age 1-4, repeated attempts.

 

Treat with nebulized epinephrine and decadron 

Term
Laryngotracheal stenosis
Definition

Prolonged intubation resulting in ischemic injury secondary to lateral wall pressure from ETT

 

edema, necrosis, and ulcerations in mucosa

 

Usually treated by surgical approach to removal of tissue 

Term
Difficult Airway
Definition

Light premedication

 

Maintain spontaneous respirations 

 

Stylet for acute angle vocal cords 

 

Term
Glidescope
Definition

Can accomadate a 1 kg baby

 

Sizes 0-4 

 

Stylet necessary for sucessful intubation

 

Sweeping tongue to left unnecessary

Term
Observation during Physcial Exam
Definition

Anesthetic depth can be inferred from the rate and pattern of respiration

 

Airway obstruction can be detected by chest wall retractions or "seesaw" paradoxical motion

 

Skin and mucous membranes confirm adequate oxygenation, a pulse oximeter reading can significantly lag behind other indices of hypoxemia 

Term
Physical Exam
Definition

Capillary refill provides valuable information about the intravascular volume and cardiac output 

 

Cool, mottled, poorly perfused extremities should be examined closely for additional evidence of hypovolemia or reduced cardiac output even if the systemic arterial pressure remains normal 

 

Progression of this mottled appearance onto the trunk indicates extreme vasoconstriction that may herald iminent cardiovascular collapse 

Term
Auscultation
Definition

Precordial stethoscope is useful during all phases of general anesthesia, as well as during transport of the child between hospital locations

 

Allows immediate detection of changes in the rate and character of heart and breath sounds

 

Gives the first warning of a physiologic alteration

 

Crisp heart tones are produced by the flow of blood through a briskly contracting heart. Myocardial depression initially results in a muffled and then in a distant quality to the heart tones 

Term
Esophageal Stethoscope
Definition

Reserved for intubated patients or when precordial violates the surgical field 

 

The proper method for accurate placement of the esophageal stethoscope is to listen while simultaneously advanding the device and placing it at the level where the heart and lung sounds are maximal 

 

In small infants, unintentional placement of the esophageal stethoscope into the stomach can easily occur 

Term
EKG
Definition
B/C ischemic changes in normal pediatric patients are rare, and because lead II provides a good view of atrial activity for arrhythmia diagnosis, the latter is recommended monitoring of pediatric patients
Term
NIBP
Definition

During routine uncomplicated cases, measurement of BP should be perfromed every 3-5 mins while child is anesthetized

 

Determination that are too frequent can result in limb ischemia 

 

BP cuff is most commonly placed on the upper arm but can be placed on the forearm, thigh, or calf

 

Inconsistent correlation of measurements obtained between the upper and lower limbs 

Term
NIBP Cuff Size
Definition

Width of BP should cover approximately 2/3 of the total length of the upper arm

 

A cuff that is too small incompletely occludes the artery, resulting in the premature return of detectable flow and falsely increases the pressure measurement

 

Error can be as great as 30 mmHg

Term
UOP
Definition

Newborns produce between 0.5 and 4 ml urine/kg per hr in the 1st 3 hr or life 

 

Urine flow, initially ranges from 15 to 60 ml/kg per day, reaches as much as 120 ml/kg per day by the end of the 1st week 

 

90% of neonates producing 0.5 to 5 ml/kg per hour 

 

Neonate who is < 1 week old, urine flow alone is NOT as sensitive index of changes in CO or intravascular 

 

Beyond neonatal period, a urine flow 0.5 to 1 ml/kg per hour usually indicates adequate renal perfusion and function 

Term
Capnography
Definition

The capnographic tracing of small infants is often characterized by the lack of an apparent alveolar plateau

 

Usually a result of a higher RR, excessive dead space in the breathing circuit, or an excessive leak around an uncuffed endotracheal tube 

Term
Pulse Ox
Definition

Doesnt instantaneously reflect the arterial saturation of the degree of desaturation 

 

When the patient is breathing high concentrations of O2 and the blood is fully saturated, a substantial decrease in PaO2 can occur without a change in SaO2 

 

Detected desaturation in children 30 seconds earlier in probes placed centrally than in those placed on fingers . By the time the value indicated by a peripheral sensor had decreased 5%, the valve indicated on central sensor was 30% to 40% lower 

Term
Laryngospasm
Definition

During inhaltion induction, pharyngeal reflexes (swallowing) are abolished whereas laryngeal reflexes remain intact

 

Secretions accumulate in the hypopharynx without swallowing and cause breath-holding resulting from central apnea, a closure of the glottis, or both

 

Positive pressure ventilation using a mask and bag instead of suctioning the pharyn would push secretions farther down into the larny, stimulate the superior laryngeal nerve, and trigger real laryngospasm 

Term
Induction
Definition

Mask without premedicatio is generally used in infants younger than 10 to 12 months because this age group readily separates from the parents 

 

Mask induction most easily by holding the end of anesthesia circuit in a cupped hand over the infants face or holding just off surface of the face 

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