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1、The Pediatric Airway小儿气道,The Pediatric Airway小儿气道,Anatomy and assessment of the pediatric airwayImaging of the pediatric airwayThe Management of difficult intubation in children,Anatomy and assessment of the,Anatomy,NoseThe nose originates in the cranial ectoderm Composed of the external nose and th
2、e nasal cavityInto the nasopharynx via the choanae or posterior nasal apertures,AnatomyNose,Anatomy,CharacteristicSoft 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 o
3、r blood,AnatomyCharacteristic,Anatomy,Paranasal sinusesethmoidal, maxillary, frontal and sphenoid sinusesairway obstruction caused by copious and tenacious secretionsCellulitis, edema or abscess formation may also occur.,AnatomyParanasal sinuses,Anatomy,PharynxIn free communication with the nasal ca
4、vity, the mouth and the larynxNasopharynx、oropharynx 、 laryngopharynx,AnatomyPharynx,Anatomy,The nasopharynx of an infant photographedwith the 120 retrograde telescope.,AnatomyThe nasopharynx of an i,Anatomy,The nasopharynx of a 5-year- old with mildcongestion of the posterior end of the septum and
5、the turbinates.,AnatomyThe nasopharynx of a 5-,Anatomy,Oropharynx,AnatomyOropharynx,Anatomy,Retropharyngeal abscess: a, abscess bulge; d,laryngoscope blade;b, uvula; c, tongue; e, tonsil,AnatomyRetropharyngeal abscess,Anatomy,Laryngopharynx,the piriform fossa,AnatomyLaryngopharynxthe pirif,Anatomy,L
6、aryngopharynx,The glottic and supraglottic structures in a 6-month-old infant.,AnatomyLaryngopharynx The,Anatomy,Laryngopharynx,Laryngeal papillomatosis,Recurrent respiratory papillomatosis,(RRP),AnatomyLaryngopharynx Lar,Anatomy,Laryngopharynx,AnatomyLaryngopharynx,Anatomy,Laryngopharynx,The presen
7、ce of mucosal edema at this site will severely compromise the airway,AnatomyLaryngopharynx The,Anatomy,Anatomy,Anatomy,Laryngopharynx,AnatomyLaryngopharynx,Assessment of the pediatric airway,Assessment of the pediatric ai,Imaging of the pediatric airway,Frontal chest radiograph in a 10-month-old inf
8、ant. 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 airwa,Imaging of the pediatric airway,expiration (a),inspiration (b),Imaging of the pediatric airwa,Imaging of the pediatric airway
9、,Two-year old with acute wheezing after eating peanuts,inspiratory radiograph (a),expiratory radiograph (b),Imaging of the pediatric airwa,Imaging of the pediatric airway,Lateral (a) Frontal (b) A double aortic arch vascular ring,Imaging of the pediatric airwa,Imaging of the pediatric airway,Sagitta
10、l ultrasonography,magnetic resonance imaging,Imaging of the pediatric airwa,Imaging of the pediatric airway,Goiter,Coronal (a) Sagittal(b) Fetal MRI T2 weighted,Imaging of the pediatric airwa,Imaging of the pediatric airway,Right bony choanal atresia.,The axial computerized tomography,Imaging of the
11、 pediatric airwa,Imaging of the pediatric airway,CT and PETCT images a 12-yearold boy with Hodgkins lymphoma hypermetabolic palatine tonsils,Imaging of the pediatric airwa,Imaging of the pediatric airway,Tracheal agenesis with bilateral esophageal bronchi CT coronal minimum intensity projection imag
12、econfirms an esophageal ETT,Imaging of the pediatric airwa,Imaging of the pediatric airway,Tracheomalacia,an 11-month male with noisy breathing demonstrates innominateartery compressing the trachea at the thoracic inlet,Imaging of the pediatric airwa,Imaging of the pediatric airway,Tracheomalacia re
13、sulting from external vascular compression,Imaging of the pediatric airwa,Imaging of the pediatric airway,Double aortic arch with tracheal narrowing,CT angiography with a volume rendered 3D image,coronal MPR (Multi-Planar Reformatted) image,Imaging of the pediatric airwa,Imaging of the pediatric air
14、way,Bronchial foreign body,Fragments of peanuts were removed from the bronchus endoscopically,Imaging of the pediatric airwa,Imaging of the pediatric airway,Mediastinal lymphoma,Imaging of the pediatric airwa,Imaging of the pediatric airway,Lateral neck radiograph of a young toddler who presented wi
15、th acute onset of hoarseness and stridor,Imaging of the pediatric airwa,The Management of difficult intubation in children,Issues must be discussed in detail with the parents!All discussions and plans should be clearly documented!,The Management of difficult in,ASAGuidelines(2003),ASA,Difficult Airw
16、ay Society guidelines Flow-chart 2004 (use with DAS guidelines paper),Difficult Airway Society guide,困难气道管理专家意见（2009）,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 OralKetamine： 48 mg kg-1 Im 3-5 min Full monitoring applied is a
17、 priority！,PremedicationThe individual ci,Premedication,Antimuscarinics,Atropine,3040 g kg-1 Oral 90min 20 g kg-1 IM 25min,Premedication Dry secr,Choice of anesthetic technique,Principle： Maintain spontaneous ventilation until the airway is secure！Cant ventilate, Cant intubate scenario,Choice of ane
18、sthetic technique,Inhalational 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 place,Choice of anesthetic technique,Inhalational technique is favo,Intravenous induction age
19、ntPreserve spontaneous respirationPropofol 0.51 mgkg-1 titrated slowlyKetamine 12 mgkg-1 again titratedDeepened with SevofluraneAn adequate plane of anesthesia has been achieved for laryngoscopy,Choice of anesthetic technique,Intravenous induction agentCho,Choice of anesthetic technique,Ephedrine an
20、d Lidocaine solutions attached to atomisers,Choice of anesthetic technique,Airway 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 induction,Choice of anesthetic t
21、echnique,Airway obstruct earlyChoice of,Polar north endotracheal tube (top) cut to length for use as a nasal airway (bottom),Choice of anesthetic technique,Polar north endotracheal tube,Golden rules : Have all equipment to hand and check before patient is in the anesthetic roomGet good assistance, m
22、ay be another experienced anesthetistPlan ahead, and have a bottom line plan a surgical airway,Choice of anesthetic technique,Golden rules :Choice of anesth,Macintosh laryngoscope the larynx cannot be viewed in an estimated 13% of cases,Equipment and techniques,Macintosh laryngoscope the lar,Convent
23、ional 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 techniques,Conventional rigid laryngoscop,Equipment and techniques,Miller blade advanced in the space between the
24、tongue and the lateral pharyngeal wall or tonsillar fossa,Equipment and techniquesMiller,Equipment and techniques,MacroglossiaMicrognathiaA straight blade laryngoscope should be first choice!,Equipment and techniques Macro,Equipment and techniques,Equipment and techniques,Equipment and techniques,Mc
25、CoyMacintosh blade for adult practice (sizes 3 & 4).Pediatric sizes on a Seward blade (sizes 1 & 2),Equipment and techniquesMcCoy,Equipment and techniques,Equipment and techniques,Equipment and techniques,Equipment and techniques,Equipment and techniques,Fiberoptic intubation,Equipment and technique
26、sFibero,Equipment and techniques,Fiberoptic intubationGood oxygenation and deep anesthesia Topical anesthesia of the airway Planning and all necessary equipmentSkilled assistance, plan and backup planEquipment 、checked(cricithyroidotomy device and high pressure ventilating device),Equipment and tech
27、niquesFibero,Equipment and techniques,Fiberoptic intubation through a laryngeal mask airway,Equipment and techniquesFibero,The unanticipated difficult intubation scenario,Soft tissue trauma and swellingHypoxemic anesthetic deathsBrain damageInadequate ventilation,The unanticipated difficult in,The u
28、nanticipated difficult intubation scenario,89% could have been prevented!Miller CG. ASA June 2000,The unanticipated difficult in,The unanticipated difficult intubation scenario,Breathing spontaneouslyClear airway Follow advice for a predicted difficult intubationUnanticipated difficult intubation do
29、es occur rarely,The unanticipated difficult in,The unanticipated difficult intubation scenario,Difficult intubation scenario after paralysisRapid Sequence InductionMade to awaken the childMaintain oxygenation and againVentilation by the best means possible.,The unanticipated difficult in,videos,videos,小儿气道课件,小儿气道课件,小儿气道课件,小儿气道课件,Thank you ！,Thank you ！,
