2. Page 2
Pediatrics
Endotracheal Intubation Objectives
•By the end of this workshop, the learner will be
able to:
•Recite at least 3 indications and 5 complications associated
with orotracheal intubation
•Derive the appropriate ETT size for orotracheal intubation
using a formula and/or the patient’s age/weight/size
•Determine the appropriate sized laryngoscopy blade
according to the patient’s age/weight/size
•Name at least 3 anatomic differences between the pediatric
and adult airway
4. Page 4
Pediatrics
8 Month Old With Respiratory
Distress
•Previously healthy male
•Fever (41C) x 2 days with cough
•P 155 R 50 BP 75/40 SpO2 85% on ambient air
•Tired-appearing, grunting, decreased aeration on
left
5. Page 5
Pediatrics
Assessment and Plan
•Assessment?
•Pneumonia
•Plan?
•Supplemental oxygen
•Peripheral IV
•IV antibiotics
•IV fluids
•+/- CXR
6. Page 6
Pediatrics
Moments Later…
•After being placed on 15 LPM non-rebreather mask
•How much FiO2 does this provide?
•SpO2 now 92%
•Still tired-appearing, grunting, subcostal retractions
•P 170 R 20 BP 70/40
•Now what?
•Intubate!
7. Page 7
Pediatrics
THE PEDIATRIC AIRWAY
From: respiratory-care-sleep-medicine.advanceweb.com/Article/Building-intubation-skills-and-confidence.aspx
8. Page 8
Pediatrics
Differences in Pediatric Airway
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
9. Page 9
Pediatrics
Differences in Pediatric Airway
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
10. Page 10
Pediatrics
Children Have Larger Tongues
•Children’s tongues are
proportionally larger
•May make it difficult to maneuver
the laryngoscope for an optimal
view
•Remember to place the blade on
the right side of the mouth and
move toward the left to move the
tongue
11. Page 11
Pediatrics
Differences in Pediatric Airway
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
12. Page 12
Pediatrics
Large, Floppy Epiglottis
•May be difficult to maneuver with the
laryngoscope blade
•The Miller (straight) blade is designed to
LIFT the epiglottis (more finesse)
•The Macintosh (curved) blade is
designed to be placed in the vallecula
and encourage the epiglottis to move
From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012
13. Page 13
Pediatrics
Differences in Pediatric Airway
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
14. Page 14
Pediatrics
The Funneled Larynx
Adult Infant
Image from: http://www.hadassah.org.il/NR/rdonlyres/59B531BD-EECC-4FOE-9E81-14B9B29D139B1945/AirwayManagement.ppt
•Narrowest point is in the subglottic
(below vocal cords) region
•Too tight of an ETT may cause
airway edema and stridor post-
extubation
15. Page 15
Pediatrics
Differences in Pediatric Airway
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
16. Page 16
Pediatrics
Pediatric Airways Are More Anterior and
Superior Than Adult Airways
Image from: http://depts.washington.edu/pccm/Pediatric%20Airway%20management.ppt
Adult Infant
•This makes proper position vital to
the success of intubation
•Common mistakes are:
• Placing the laryngoscope blade too far
• Hyperextension of the neck
•Sometimes, you may need to
gently manipulate the thyroid
cartilage to move the larynx into
view (BURP)
19. Page 19
Pediatrics
Indications for Intubation
•Primary respiratory disorder
• Severe hypoxemia (pneumonia, ARDS)
• Severe hypoventilation (bronchiolitis, emphysema, CLD)
•Primary neuromuscular disorder
• Myopathy (DMD, SMA)
• Altered mental status with hypoventilation (TBI, intoxication)
• Lack of airway protection (TBI, severe HIE, intoxication)
• Need for sedation with risk of airway protection or ventilation
•Tight control of paCO2 or pH
• Severe increased ICP (paCO2)
• Severe pulmonary hypertension (pH)
•To reduce metabolic demands in severe shock
20. Page 20
Pediatrics
Use SOAP to Prepare for Intubation
•Suction
•Rigid catheter with constant suction (Yankauer)
•Oxygen
•10-15 LPM 100% (make sure it is not on a blender)
•Airway
•Appropriate sized tubes (estimated size and ½ size smaller)
•Appropriate sized laryngoscope blades
•Oral airways
•Pharmacology
•Based on disease
www.mountainside-medical.com/products/Yankauer-Suction-Tip-Handle.html
21. Page 21
Pediatrics
Medications for Intubation
•Premedication for laryngoscopy
•Sedation +/- analgesia
•Neuromuscular blockade
•Make sure you can ventilate prior to neuromuscular blockade
•Make sure you can ventilate prior to neuromuscular blockade
•Make sure you can ventilate prior to neuromuscular blockade
22. Page 22
Pediatrics
Premedication
•Atropine (neonates, infants)
•0.02 mg/kg IV (0.1 – 1 mg total dose)
•Blunts the vagal response from laryngoscopy
•Use if bradycardic/risk of bradycardia
•Lidocaine (TBI, elevated ICP)
•1 mg/kg IV
•Anesthetizes airway to blunt the ICP spike from laryngoscopy
23. Page 23
Pediatrics
Sedation
•Midazolam (85% of routine patients)
• 0.1 – 0.2 mg/kg IV
•Fentanyl (85% of routine patients)
• 2 – 6 mcg/kg IV (slow infusion, may cause rigid chest)
• Give sedative with fentanyl (no sedative effect)
•Propofol
• 1 mg/kg IV (may cause hypotension)
•Ketamine (shock states, asthma)
• 1 – 3 mg/kg IV (may cause increased bronchorrhea)
• 2 mg/kg IV for RSI
•Thiopental vs. Etomidate (elevated ICP)
• Thiopental 3 – 5 mg/kg IV (high risk of hypotension)
• Etomidate 0.2 – 0.6 mg/kg IV (may cause adrenal suppression)
24. Page 24
Pediatrics
Neuromuscular Blockade
•Rocuronium vs. Vecuronium (85% of patients)
• Rocuronium 0.6 – 1.2 mg/kg IV (1.5 – 2 mg/kg IV for RSI)
• Vecuronium 0.1 – 0.4 mg/kg IV
• Effect may be prolonged in renal/hepatic failure
•Cisatracurium
• 0.2 mg/kg IV
• Cleared by Hoffman degradation (good for renal/hepatic failure)
•Succinylcholine
• 1 – 2 mg/kg IV; 4 mg/kg IM
• Patient will fasciculate, consider a defasciculating dose of rocuronium/vecuronium
(1/10 dose)
• Beware of hyperkalemia in patients with neuromuscular disorders, burns, crush
injuries, renal failure
26. Page 26
Pediatrics
Laryngoscope and ETT Selection
•Match the patient! If the patient is smaller than
stated age (or unknown age), ETT can be
estimated by the patient’s 5th finger size
Age Blade Size & Type ETT Size (mm; Uncuffed &
Cuffed)
NB < 2 kg 0 Miller 2.5
NB > 2 kg ~ 6 mo 1 Miller 3.5 or 3.0 C
6 mo ~ 1 yr 1 ~ 1.5 Miller 4.0 or 3.5 C
1 yr ~ 2 yr 1.5 Miller 4.5 or 4.0 C
2 yr ~ 8 yr 2 Miller For UNcuffed tubes:
8 yr ~ 12 yr 2 Miller or 2 Macintosh
> 12 yr 3 Miller or 3 Macintosh
Age(yrs)
4
+ 4 Subtract 0.5 mm
for Cuffed tubes
29. Page 29
Pediatrics
Alignment of The Airway:
Children <3 years
McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84
O: Oral axis
P: Pharyngeal axis
L: Laryngeal axis
Large occiput
flexes head and
neck Shoulder roll will
help line up the
pharyngeal and
laryngeal axes
Extension of
atlantooccipital joint
will line up oral axis
with the other two
30. Page 30
Pediatrics
Placement of the Laryngoscope
Blade (< 3 years)
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
Shoulder Roll for Infants
31. Page 31
Pediatrics
Alignment of The Airway:
Children >3 years
McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84
O: Oral axis
P: Pharyngeal axis
L: Laryngeal axis
Cushion under head
will flex neck to line
up pharyngeal and
laryngeal axes
Extension of
atlantooccipital joint
will line up oral axis
with the other two
32. Page 32
Pediatrics
Placement of the Laryngoscope
Blade (> 3 years)
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
36. Page 36
Pediatrics
How Do You Confirm Intubation?
•Bilateral & equal breath sounds
•If decreased on one side?
•If absent on one side and hypertympanic
•Improvement of oxygenation
•If saturations rapidly decrease?
•EtCO2 confirmation
•Colorimetric: Yellow = Yes
•Waveform analysis/quantitative: > 15 mm Hg
•CXR confirmation
•Absent sounds over stomach
•Mist in ETT during bag-ventilation
37. Page 37
Pediatrics
Potential Complications of Oral
Intubation
•Inability to ventilate (difficulty intubating and cannot BMV)
• This can lead to death
• Make sure you can ventilate prior to neuromuscular blockade
•Tube malposition (esophageal intubation)
• What will you notice/see?
•Airway trauma
• Teeth (check for loose or missing teeth before and after)
• Vocal cord injury (ineffective paralytic/VC closed during insertion)
• Subglottic edema/stenosis (incorrect tube size)
•Pulmonary disease
• Mainstem (left or right) intubation
• Pneumothorax (usually from over-exuberant bagging)
40. Page 40
Pediatrics
Endotracheal Intubation Objectives
•By the end of this workshop, the learner will be
able to:
•Recite at least 3 indications and 5 complications associated
with orotracheal intubation
•Derive the appropriate ETT size for orotracheal intubation
using a formula and/or the patient’s age/weight/size
•Determine the appropriate sized laryngoscopy blade
according to the patient’s age/weight/size
•Name at least 3 anatomic differences between the pediatric
and adult airway