1. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU Jeffrey Burns, M.D., M.P.H. Chief, Division of Critical Care Medicine Children’s Hospital Boston Associate Professor of Anesthesia and Pediatrics Harvard Medical School

2. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The critical airway concept The difficult airway algorithms Predicting a difficult airway The intubation checklist

3. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The critical airway concept The difficult airway algorithms Predicting a difficult airway The intubation checklist

4. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU “Although technical difficulty is the most feared and studied aspect of airway management, it is not the only aspect impacting the progression of events. The outcome of the critical care airway management is the result of many variables not included in difficult airway management algorithms….” Matioc, Adrian A. MD; Arndt, George MD; Jofee, Aaron MD The critical airway: The difficult airway in the adult critical care. Critical Care Medicine. 37(3):1175- 1176, March 2009.

5. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU “Airway management in the intensive care unit is not a single provider technical event. The critical airway (CA) concept can be used to address organizational needs for airway management in the intensive care unit. CA management starts with the design of the patient's bed, the workplace (intensive care unit room), and the airway device such that it will allow an ergonomic approach to the patient's airway in minimal time. It also assumes training of the “helping” staff and continuous effort from the airway provider to improve clinical and technical skills.” Matioc, A; Arndt, G; and Jofee, A: The critical airway: The difficult airway in the adult critical care.[Letter] Critical Care Medicine. 37(3):1175-1176, March 2009.

6. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The difficult airway has been defined as “the clinical situation in which a conventionally trained anesthetist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both” Yet all patients in the Pediatric ICU should initially be viewed as having a potentially “critical” airway Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork.

7. Increased oxygen consumption in the pediatric patient: less reserve time to manage the airway

8. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The critical airway concept The difficult airway algorithms Predicting a difficult airway The intubation checklist

14. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The critical airway concept The difficult airway algorithms Predicting a difficult airway The intubation checklist

16. Predicting a Difficult Airway Clinical Examination mouth opening back of mouth-Mallampati ?lower teeth ride beyond upper teeth Movement of the cervical spine C 2 -C 8 =nodding to and fro Delikan warning sign

17. Predicting a Difficult Airway Anatomical Distance * Critical Distance Thyro-mental distance6.0 cm (Patil distance) Sterno-mental distance12.5 cm (Savva distance) *Head fully extended on the neck with mouth closed

18. Causes of a Difficult Airway Improper Positioning Anatomical Abnormalities Musculoskeletal Problems Cervical Rigidity Temporomandibular Joint Disorders Inflammatory Processes Neoplasms Trauma

19. Causes of a Difficult Airway Improper Positioning

20. Positioning for Tracheal Intubation

22. Preparing for the Critical Airway-not just the Difficult Airway-in the PICU The critical airway concept The difficult airway algorithms Predicting a difficult airway The intubation checklist

23. Would you fly with pilots who did not perform the takeoff checklist?

25. Predicting a Difficult Airway Clinical History Clinical Examination Mouth Opening-Mallampati Classification Jaw Movement Inspection of the Mouth Cervical Spine Mobility Measurements

26. “BURP” Displace the Thyroid cartilage Backwards, Upwards, and to the Right Knill RL. Difficult laryngoscopy made easy with a ‘‘BURP’’. Canadian Journal of Anaesthesiology 1993;40:279–82.

28. Mind what you have learned. Save your patient it can!

29. Jeffrey.Burns@Childrens.Harvard.EDU No conflicts or financial disclosures to convey