This document provides information on pediatric endotracheal intubation for medical trainees. It outlines the objectives of learning how to intubate children, which include being able to state indications for intubation, recognize potential complications, select the proper endotracheal tube size, and identify anatomical differences between the pediatric and adult airway. The document then reviews a case study of an 8 month old infant with respiratory distress who requires intubation. It discusses appropriate preparations, medications, techniques, and post-intubation care considerations for pediatric intubation.

1. Pediatrics
Fong Lam, MD
Baylor College of Medicine
Critical Care Medicine Boot Camp
Endotracheal
Intubation

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

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Pediatrics
8 MONTH OLD WITH
RESPIRATORY DISTRESS

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

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Pediatrics
Assessment and Plan
•Assessment?
•Pneumonia
•Plan?
•Supplemental oxygen
•Peripheral IV
•IV antibiotics
•IV fluids
•+/- CXR

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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

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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

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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

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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

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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)

17. Page 17
Pediatrics
Difficulty Viewing the Cords? BURP
Image from: Carrillo-Esper et al. Rev Mex Anes. 2008

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Pediatrics
PREPARING FOR INTUBATION

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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

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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

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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)

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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

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Pediatrics
ENDOTRACHEAL INTUBATION

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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

27. Page 27
Pediatrics
Choose Your Blades
Miller Blades Macintosh Blades

28. Page 28
Pediatrics
http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259
Head Tilt-Chin Lift Maneuver

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

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Pediatrics
Laryngoscopic View
From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right)

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Pediatrics
ETT Insertion Depth – How Far?
•3 x ETT size
•Black marking or cuff past vocal cords

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Pediatrics
POST-INTUBATION CARE

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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)

38. Page 38
Pediatrics
Pneumothorax
From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)

39. Page 39
Pediatrics
Dental Trauma (DON’T DO THIS)
From: Windsor and Lockie. Anaesth and Int Care Med. 2008

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

41. Page 41
Pediatrics
QUESTIONS?