New episode & already a favorite – what are “The Airways That Scare” Robi Khemani @ChildrensLA? What does a world leader in #pedsICU resp disease actually do w his toughest patients? https://t.co/BXX9gcYbPW #AirwayManagement #resus @drgregkelly @drpetaalexander @karen_choong

Incredible discussion on the high risk intubation of the child with severe respiratory failure. See below for some of the highlights. Thanks @PedsIntensiva for the great work on this!

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong End of this episode on #AirwayManagement in #pedsICU respiratory patients! More info & references on show page (link below) Please: 1. Follow us @PedsIntensiva for more 2. Retweet the 1st tweet below to share this thread #resus https://t.co/BXX9gcYbPW

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Extubation Readiness Preparation #3: - If no resp muscle weakness (PI max > 30) and flew on CPAP only SBT -> exubate to low flow O2 & escalate if need - Pre existing NIV -> extubate to NIV - Risk factors like resp muscle weakness, eked by SBT -> prophylactic NIV / HF #pedsICU

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Extubation Readiness Assessment & Preparation #2: - CPAP only (no pressure support) 2hr spont breathing trial on all but low risk pts (e.g. seizure) - Robi: patients REALLY don't need pressure support for SBT! - Steroids if no leak w cuffed ETT #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Finally, Extubation Readiness Assessment & Preparation: - Use a bundle - Assess PI max / NIF - If PI max lower than -30 = higher risk patient due to resp. muscle weakness so consider extubation to NIV / HF https://t.co/55BZ5Ktukt #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong The toys you have #2 - Assess resp effort on both intubated AND non-intubated patients visually and using maneuvers - Exp occlusion / exp hold - P 0.1 (P point 1 / P zero 1) Robi does these on every ventilated pt daily https://t.co/pU6JSdbVI0 #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong A 4 cont' the toys you have 1: - Measure plateau pressure, DO NOT assume peak = plateau, could be ⬆ if spont venting or ⬇ depending on insp. time - Pplat guides volume, pressure, sedation & NMB choices #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Burning Q 4. We all love toys but what do you actually need? A: - I love it all but you don't need it all to make decisions for all but a handful of pts - You can mostly use the tools that you have but get a LOT more information out of them #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Burning Q 3. Blood gases in bronchiolitis - tear up the paper, or?... A: - I don't order them but they seem to get done! - Context is key. Single gas is less useful than trends over time. Contextualize with patient’s trajectory. #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong A, pt with necrotizing pneumonia & high work: - Decide what's going on, is high work high transpulmonary pressure (bad) or airway resistance (less bad) - If high work w ok sats, less bad - Effect of high work on other organs - Watch over time #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Burning Q 2. Necrotizing pneumonia that has high work of breathing regardless of support (ECMO, ventilator, extubated.) How to progress?

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Empyema A: - Depends on pt, team & comfort level, #pedsICU clinicians put in few chest drains now - POCUS can help judge if compromise from effusion vs lung vs CV impairment (function, filling) - Bedside drain may not be ideal c.f what surgeons / IR place #AirwayManagement

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong 🚨 Burning Questions Segment Q1: In patients w empyema & cardioresp compromise should we intubate or drain the effusion first? Advantage of chest drain 1st-effusion may be major reason for cardioresp compromise vs drain easier in paralysed pt #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong How does Robi recruit the lung AFTER intubation? #2 - Once at ceiling of PEEP 20, decremental PEEP titration in steps of 2 (4 if appeared overdistended at ceiling) - Monitoring "poor man's compliance" of tidal volume for fixed delta P to find PEEP @ optimal compliance #pedsICU

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong How does Robi recruit the lung AFTER intubation? - Use ventilator - PC mode delta P~15, rate 15-20 - Incremental PEEP increase in steps of 2-4 to 20 cmH20 (25 in v obese) Monitor hemodynamics & SpO2 to ensure not overdistending & compromising #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Video laryngoscopy game changer for shared visualization and better coaching with learners #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Apneic oxygenation DURING laryngoscopy: Approach differs between not using apox for this phase, continuing nasal cannula or HFNC or continuing nasal BiPAP (although may make laryngoscopy harder and few seem to do in practice. #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Apneic oxygenation & recruitment PRE laryngoscopy: Approach differs - can continue NIV, mask ventilate, use regular nasal cannula with flow ⬆ or HFNC HFNC hard to mask ventilate over whereas w regular nasal cannula it's usually possible #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Preoxygenation and pre-recruitment (pre NMB): - High FiO2 - PEEP Many patients being intubated off NIV which is ideal for both. Anesthetic bag (Ayer's T piece) or self inflating bag w PEEP valve also widely used. Depends on local availability #AirwayManagement #pedsICU #resus

@ChildrensLA @drgregkelly @drpetaalexander @karen_choong Preparation matters for #AirwayManagement, esp. in higher risk patients as mentioned earlier - Standardized process + checklist - Equipment incl. etCO2, manometer - Team - Environment Whole episode on these factors here https://t.co/ivxLMEUyeV #pedsICU #resus