1、 The nose originates in the cranial ectoderm Composed of the external nose and the nasal cavity Into the nasopharynx via the choanae or posterior nasal aperturesCharacteristic Soft and distensible,with relatively more mucosa and lymphoid tissue than in the adult Deviationof the nasal septum occurs i
2、n all ages of children easily obstructed by secretions,edema or blood ethmoidal,maxillary,frontal and sphenoid sinuses airway obstruction caused by copious and tenacious secretions Cellulitis,edema or abscess formation may also occur.In free communication with the nasal cavity,the mouth and the lary
3、nx Nasopharynx、oropharynx、laryngopharynxThe nasopharynx of an infant photographedwith the 120 retrograde telescope.The nasopharynx of a 5-year-old with mildcongestion of the posterior end of the septum and the turbinates.Retropharyngeal abscess:a,abscess bulge;d,laryngoscope blade;b,uvula;c,tongue;e
4、,tonsilthe piriform fossa The glottic and supraglottic structures in a 6-month-old infant.Laryngeal papillomatosisRecurrent respiratory papillomatosis(RRP)The presence of mucosal edema at this site will severely compromise the airway Sleep studiesEndoscopyImagingInvestigationsExaminationHistory Fron
5、tal 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.expiration(a)inspiration(b)Two-year old with acute wheezing after eating peanutsinspiratory radiograph(a)expiratory rad
6、iograph(b)Lateral(a)Frontal(b)A double aortic arch vascular ringSagittal ultrasonographymagnetic resonance imagingGoiterCoronal(a)Sagittal(b)Fetal MRI T2 weightedRight bony choanal atresia.The axial computerized tomography CT and PETCT images a 12-yearold boy with Hodgkins lymphoma hypermetabolic pa
7、latine tonsils Tracheal agenesis with bilateral esophageal bronchi CT coronal minimum intensity projection imageconfirms an esophageal ETT Tracheomalaciaan 11-month male with noisy breathing demonstrates innominateartery compressing the trachea at the thoracic inletTracheomalacia resulting from exte
8、rnal vascular compression Double aortic arch with tracheal narrowingCT angiography with a volume rendered 3D imagecoronal MPR(Multi-Planar Reformatted)image Bronchial foreign bodyFragments of peanuts were removed from the bronchus endoscopically Mediastinal lymphoma Lateral neck radiograph of a youn
9、g toddler who presented with acute onset of hoarseness and stridor 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 paper)困难气道管困难气道管理专家意见理专家意见（2009
10、）The individual circumstances of every case must be considered!Midazolam：0.30.5 mg kg-1 Oral Ketamine：48 mg kg-1 Im 3-5 min Full monitoring applied is a priority！Dry secretions Heart rateAntimuscarinicsAtropine3040 g kg-1 Oral 90min 20 g kg-1 IM 25min Principle：Maintain spontaneous ventilation until
11、 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 placeIntravenous induction agentPreserve spontaneous
12、respirationPropofol 0.51 mgkg-1 titrated slowlyKetamine 12 mgkg-1 again titratedDeepened with SevofluraneAn adequate plane of anesthesia has been achieved for laryngoscopyEphedrine and Lidocaine solutions attached to atomisersAirway obstruct earlyTurned into the lateral positionA soft nasal airway s
13、hould be placed to clear the airwayImprove the airway allowing the anesthetist to avoid oral airways till later in the inductionPolar north endotracheal tube(top)cut to length for use as a nasal airway(bottom)Golden rules:Have all equipment to hand and check before patient is in the anesthetic roomG
14、et good assistance,may be another experienced anesthetistPlan ahead,and have a bottom line plan a surgical airwayMacintosh laryngoscope the larynx cannot be viewed in an estimated 13%of casesConventional rigid laryngoscopes:Tongue:size,obscure the view,in the oral cavity Mandible:underdeveloped Lary
15、nx:a higher position A poor view with a curved rigid laryngoscope.Miller blade advanced in the space between the tongue and the lateral pharyngeal wall or tonsillar fossau MacroglossiauMicrognathiaA straight blade laryngoscope should be first choice!McCoyMacintosh blade for adult practice(sizes 3&4)
16、.Pediatric sizes on a Seward blade(sizes 1&2)Fiberoptic intubationFiberoptic 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 ventila
17、ting device)Fiberoptic intubation through a laryngeal mask airwayuSoft tissue trauma and swellinguHypoxemic anesthetic deathsuBrain damageMiller CG.ASA June 2000uBreathing spontaneouslyuClear airway uFollow advice for a predicted difficult intubationDifficult intubation scenario after paralysis Rapid Sequence Induction Made to awaken the child Maintain oxygenation and again Ventilation by the best means possible.
