This document provides guidance on pediatric intubation. It discusses indications for intubation in pediatric patients, how pediatric airways differ from adults, important considerations before intubation, equipment and medications needed, and techniques for performing intubation. Key differences in pediatric airways include a larger tongue, angled vocal cords, differently shaped epiglottis, and a funnel-shaped larynx. Important assessments before intubation include evaluating mouth opening, neck mobility, and airway anatomy. Common induction agents described are etomidate, propofol, ketamine, and fentanyl/versed. Succinylcholine, rocuronium, and cisatracurium are paralytic options. Case examples are provided

1. Pediatric Intubation
Rob Parker, DO
Pediatric Critical Care Fellow
March 11, 2016

3. Outline
 Indications
 How are kids different
 What to know before you intubate
 The set up
 What drugs
 How to perform
 Scenarios

4. Indications for Intubation
 Primary respiratory disorder
– Severe hypoxemia (pneumonia, ARDS)
 PaO2 <60 mmHg on 60% FiO2
– Severe hypoventilation (bronchiolitis, emphysema, CLD)
 PaCO2 >50 mmHg occurring in an acute manner
 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

5. How Are Kids Different
 Airway positioning
 Larger tongue
 Angled vocal cords
 Differently shaped epiglottis
 Funneled shaped larynx with differing narrowmost
point

6. Airway positioning

7. Neutral
position
Simple head extension
“Sniffing”
position

8. Head Position

9. Sniffing Position or “Ear to Sternal Notch”

10. Larger Tongue and Angled Vocal Cords

11. Different Shaped Epiglottis

12. Funnel Shaped Larynx

13. Summary of Differences

14. Things You Should Know BEFORE You Intubate

15. Look
 Look for normal
face and anatomy
– Pierre Robin,
Treacher Collins,
Achondroplasia,
Cleft lip/palate,
Down Syndrome,
Crouzon,
Goldenhar, Apert,
Mucopolysaccari
dosis
– Tumors, trauma
– “Buck teeth,”
missing teeth,
obesity, cervical
immobility
Pierre Robin S.
Down S.
Achondroplasia
Crouzon S.
Treacher Collins S.
Goldenhar S.
Apert S.
Mucopolysaccaridosis

16. Evaluate 3-3-2
 3 finger breadths of mouth opening
 3 finger breadths submental to hyoid
 2 finger breadths hyoid to thyroid

17. Mallampati

18. Obstruction

19. Neck Mobility

20. LEMON’s
 LEMON is nearly 100% predictive of a difficult airway
in adults
– However, it has not been validated completely in kids
– Look
 Short neck, large tongue, micrognathia
– Evaluate 3-3-2
 3 finger breadths of mouth opening
 2 finger breadths submental to hyoid (potential displacement
area)
 2 finger breadths hyoid to thyroid
– Mallampati
– Obstruction
– Neck mobility

21. The Set Up

22. SOAP - ME
 Suction
– Large Bore (Yankauer)
– Small Bore (Oxygen suction or
flexible)
 Oxygen
– Pre-oxygenate with 100% FiO2
for 5 min
– May be able to do 5-8 large
volume breaths
 Airway
– Appropriately sized tubes
– Appropriately sized blades
– Oral and nasal airways
 Personnel
– RT, nursing, fellow/attending,
sedation provider
 Medications
– Premedication
– Induction
– Paralytic
– Rescue medications (epi, fluids)
 Equipment
– Vent
– BVM
– ETT, stylet, syringe
– Ways to secure ETT
– End tidal CO2, Capnography
– Working IV
– CXR

23. Miller Vs Mac

24. The Blade
Miller
 Thinner, straight blade
 Miller blade is preferred for
infants and younger children
 Facilitates lifting of the
epiglottis and exposing the
glottic opening
 Placed on top of epiglottis
lifting away
 Possibly better control of
tongue
Mac
 Wider, curved blade
 Mac tends to be used for
older children and adults
 Curves around tongue
 Placed into vallecula and lift
away
 Possibly wider glottic
opening

25. Generalities
 Miller #1 for children < 1 year
 Macintosh #2 for children 1-
10 years
 Macintosh #3 for children 11-
18 years

26. How Big and How Deep
 ETT size
– Uncuffed: 4 + (Age
(yrs)/4)
– Cuffed: 3 + (Age/4)
– (16 + Age)/4
 ETT Depth:
– ETT size * 3
– (Age/2) + 12

27. Cuff Vs Uncuff
 Old School:
– Uncuff for under 8yo to help prevent subglottic stenosis
and avoid post-extubation stridor
– Deakers et al. J Peds1994 study of 188 kids (95 uncuff,
93 cuff) showed no difference in post-extubation stridor
– Newth et al. J Peds 2004 study of 387 kids showed no
difference in use of racemic post extubation
 Current teaching:
– Cuffed tubes universally preferred
– Enables better oxygenation/ventilation
– Better for severe lung disease

28. RSI – The 7 P’s
 Preparation
– Correct indication, equipment, personnel
 Preoxygenation
– 100% FiO2, assisted breaths if clinically indicated
 Pretreatment
– Atropine, lidocaine, robinol
 Put to Sleep
– Etomidate, propofol, ketamine, fentanyl/versed
 Paralyze
– Sux, vec, roc, cis
 Pass tube
– Direct laryngoscopy, video laryngoscopy, fiberoptic
 Placement Verification
– Capnography, EtCO2, auscultation, mist, chest rise, CXR

29. Preoxygenate

30. Pretreatment
 Lidocaine:
– Blunts rise in ICP with laryngoscopy
– No good data on validity of claim
– Rx: 1-2mg/kg
 Atropine:
– Thought to blunt vagal response and prevent bradycardia;
also helps with secretions
– No good data
– Not necessarily recommended but often used in very young
children
– Rx: 0.02mg/kg with no min dose any more
 Glycopyrrolate:
– Can dry secretions some and give a slight increase to HR
– Rx: 5mcg/kg

31. Put to Sleep
 Etomidate
 Propofol
 Ketamine
 Fentanyl/versed

32. Etomidate
 Non narcotic, non barbiturate sedative
 Fast, reliable, hemodynamically stable
 Decreases cerebral blood flow and metabolic oxygen
demand lowering ICP
 Can cause adrenal suppression with a single dose
 Can cause myoclonic jerks/hiccups
 Rx:
– 0.3mg/kg
– Works in 15-30 seconds
 Who:
– Hemodynamically unstable pts without sepsis (heart pts, ICP
pts)

33. Propofol
 Alkphenol sedative hypnotic
 Fast acting and easily titratable
 Decreases cerebral metabolic oxygen demand and
lowers ICP
 Antiepileptic and antiemetic properties
 Can lower BP
 Rx:
– 1-4 mg/kg
– Works in 30-60 seconds
 Who:
– Pts with ICP issues, many respiratory pts, elective
intubations for AMS

34. Ketamine
 PCP derivative that provides analgesia, anesthesia and
amnesia
 Minimal respiratory depression and hemodynamically
stable
 Bronchodilation
 Can increase cerebral metabolic oxygen demand and ICP
 Causes increased secretions and emergence phenomenon
 Can cause laryngospasm
 Rx:
– 1-2mg/kg
– Works in 1-2 min
 Who:
– Asthma, potentially hemodynamically unstable pts

35. Fentanyl/Versed
 Opioid and benzo combination
 Analgesia, amnesia and anesthesia
 Dose dependent respiratory depression
 Minimal hemodynamic instability
 Nearly universally applicable
 Wider therapeutic window with less consistent sedation
 Rx
– Fentanyl 2-4 mcg/kg over 2 min to avoid rigid chest
– Versed 0.1 mg/kg
 Who:
– Most anyone

36. Succinylcholine
 Depolarizing muscle relaxant
 Potent, reliable and fast acting with quick offset
 Good for rapid sequence intubation
 Contraindicated in hyperkalemia, burns, trauma, increased
IOP, likely ICP, mitochondrial and neuromuscular kids
 Rx:
– 1-2 mg/kg
– Onset 60 seconds and lasts 5‐10 minutes
 Who:
– Most people unless contraindicated

37. Vecuronium
 Nondepolarizing muscle relaxant
 No contraindications
 Works rapidly
 Rx:
– 0.1mg/kg
– Onset in 90-120 seconds and lasts 15-60 min
 Who:
– Most anyone
– Can stay around in renal failure patients

38. Rocuronium
 Nondepolarizing muscle relaxant
 No contraindications
 Works rapidly
 Rx:
– 0.6-1.2mg/kg (1mg/kg for ease)
– Onset is 60 seconds and lasts 20-40 min
 Who:
– Most anyone

39. Cisatracurium
 Nondepolarizing muscle relaxant
 Safe in hepatic and renal failure
 Hoffman degredation
 Fast onset and offset
 May cause hypotension and histamine release with
prolonged use
 Rx:
– 0.2mg/kg
– Onset of 2 min and lasts 20 min
 Who:
– Renal and liver failure patients

40. Full view of larynx in child

41. Child laryngoscopy Miller blade

42. Infant laryngoscopy Miller blade

43. Child Miller large tonsils

44. Wisconsin blade, difficult infant laryngoscopy

45. Cases
 12yo asthmatic with impending respiratory failure
secondary to a viral illness
 Tube Size:
– 6.5-7.0
 Depth:
– 19.5-21
 Induction:
– Ketamine, maybe propofol
 Paralytic:
– Any

46. Cases
 4yo with AMS and large posterior fossa mass with
midline shift
 Tube size:
– 4.5-5.0
 Depth:
– 13.5-15
 Induction:
– Propofol, etomidate (lidocaine)
 Paralytic:
– Roc (not sux)

47. Cases
 8mo with bronchiolitis and respiratory failure
 Tube size:
– 4.0
 Depth:
– 12
 Induction:
– Propofol, fentanyl/versed (? Atropine)
 Paralytic:
– Any

48. Cases
 16yo with toxic shock on pressors and AMS
 Tube size:
– 7.0-7.5
 Depth:
– 21-23
 Induction:
– Ketamine, fentanyl/versed, maybe etomidate
 Paralytic:
– Any

49. Thank You
Questions?

50. Intubation Drugs for Pediatric Patients

51. Braslow Tape