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1、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,NoseThe nose originates in the cranial ectoderm Composed of the external nose and the nasal cavityInto the nasopharynx via the choanae or p
2、osterior nasal apertures,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 or blood,Anatomy,Paranasal sinusesethmoidal,maxillary,frontal and sphe
3、noid sinusesairway obstruction caused by copious and tenacious secretionsCellulitis,edema or abscess formation may also occur.,Anatomy,PharynxIn free communication with the nasal cavity,the mouth and the larynxNasopharynx、oropharynx、laryngopharynx,Anatomy,The nasopharynx of an infant photographedwit
4、h the 120 retrograde telescope.,Anatomy,The nasopharynx of a 5-year-old with mildcongestion 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,Anatomy,Laryngopharynx,the piriform fos
5、sa,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 site will severely compromise the
6、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 sign,also a normal variant.,Imaging o
7、f 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 aortic arch vascular ring,Imaging of the pediatric
8、 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 pediatric airway,CT and PETCT images a 12-yearold
9、 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,Tracheomalacia,an 11-month male with noisy breathing
10、 demonstrates innominateartery 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 angiography with a volume rendered 3D image,coronal M
11、PR(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 neck radiograph of a young toddler who presented wi
12、th 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!,ASAGuidelines(2003),Difficult Airway Society guidelines Flow-chart 2004(use with DAS guidelines pape
13、r),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 priority！,Premedication,Antimuscarinics,Atropine,3040 g kg-1 Oral 90min 20 g kg-1 IM 25min,Choice of anesthetic tec
14、hnique,Principle：Maintain spontaneous ventilation until the airway is secure！Cant ventilate,Cant intubate scenario,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 ta
15、ke place,Choice of anesthetic technique,Intravenous 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 laryngoscopy,Choice of anesthetic technique,Choice of
16、 anesthetic technique,Ephedrine and Lidocaine solutions attached to atomisers,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 anestheti
17、c 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 roomGet good assistance,may be another experienced anesthetistPlan ahead,and have a botto
18、m 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,obscure the view,in the oral cavityMandible:underdevelopedLarynx:a higher position A poor
19、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 techniques,MacroglossiaMicrognathiaA straight blade laryngoscope should be first choice!,Equ
20、ipment and techniques,Equipment and techniques,McCoyMacintosh blade for adult practice(sizes 3&4).Pediatric sizes on a Seward blade(sizes 1&2),Equipment and techniques,Equipment and techniques,Equipment and techniques,Fiberoptic intubation,Equipment and techniques,Fiberoptic intubationGood oxygenati
21、on 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 techniques,Fiberoptic intubation through a laryngeal mask airway,The unant
22、icipated difficult intubation scenario,Soft tissue trauma and swellingHypoxemic anesthetic deathsBrain damageInadequate ventilation,The unanticipated difficult intubation scenario,89%could have been prevented!Miller CG.ASA June 2000,The unanticipated difficult intubation scenario,Breathing spontaneo
23、uslyClear airway Follow advice for a predicted difficult intubationUnanticipated difficult intubation does occur rarely,The unanticipated difficult intubation scenario,Difficult intubation scenario after paralysisRapid Sequence InductionMade to awaken the childMaintain oxygenation and againVentilation by the best means possible.,videos,Thank you！,
