2. Objectives
By the end of this workshop, the learner will:
‐ 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
‐ Carry out the proper sequence of events involved in
orotracheal intubation
Pediatrics
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4. 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
Pediatrics
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5. Use SOAP to Prepare for Intubation
‐ 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
‐ Airway adjuncts
•Pharmacology
Pediatrics
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www.mountainside‐medical.com/products/Yankauer‐Suction‐Tip‐Handle.html
•Suction
6. 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
Pediatrics
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7. 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
Pediatrics
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8. Sedation
• Ketamine (shock states, asthma)
• Midazolam (85% of routine
patients)
‐ 1 – 3 mg/kg IV (may cause
increased bronchorrhea)
‐ 0.1 – 0.2 mg/kg IV
‐ 2 mg/kg IV for RSI
• Fentanyl (85% of routine patients)
‐ 2 – 6 mcg/kg IV (slow infusion,
may cause rigid chest)
• Thiopental vs. Etomidate (elevated
ICP)
‐ Thiopental 3 – 5 mg/kg IV (high risk
of hypotension)
‐ Give sedative with fentanyl (no
sedative effect)
‐ Etomidate 0.2 – 0.6 mg/kg IV (may
cause adrenal suppression)
• Propofol
‐ 1 mg/kg IV (may cause
hypotension)
Pediatrics
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9. Neuromuscular Blockade
• Rocuronium vs. Vecuronium (85% • Succinylcholine
of patients)
‐ 1 – 2 mg/kg IV; 4 mg/kg IM
‐ Rocuronium 0.6 – 1.2 mg/kg IV
(1.5 – 2 mg/kg IV for RSI)
‐ Patient will fasciculate, consider
a defasciculating dose of
rocuronium/vecuronium (1/10
dose)
‐ Vecuronium 0.1 – 0.4 mg/kg IV
‐ Effect may be prolonged in
renal/hepatic failure
‐ Beware of hyperkalemia in
patients with neuromuscular
disorders, burns, crush injuries,
renal failure
• Cisatracurium
‐ 0.2 mg/kg IV
‐ Cleared by Hoffman degradation
(good for renal/hepatic failure)
Pediatrics
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11. 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 5 th
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
Pediatrics
Age(yrs)
+4
4
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Subtract 0.5 mm
for Cuffed tubes
12. Choose Your Blades
Miller Blades
Pediatrics
Macintosh Blades
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13. Head Tilt-Chin Lift Maneuver
http://utdol.com/utd/content/topic.do?topicKey=ped_res/2259
Pediatrics
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14. Alignment of The Airway:
Children <3 years
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
McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249‐84
Pediatrics
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15. Placement of the Laryngoscope
Blade (< 3 years)
Shoulder Roll for Infants
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
Pediatrics
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16. Alignment of The Airway:
Children >3 years
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
McAllister J D and K A Gnauck. Pediatr Clin North Am. 1999. 46(6): 1249-84
Pediatrics
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17. Placement of the Laryngoscope
Blade (> 3 years)
From: Foltin et al (eds). Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP). 2001
Pediatrics
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18. Laryngoscopic View
From: Kakodkar et al. In: Harnick et al. (eds) Pediatric Airway Surgery 2012 (Left); Gray’s Anatomy 1918 (Right)
Pediatrics
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19. ETT Insertion Depth – How Far?
•3 x ETT size
•Black marking or cuff past vocal cords
Pediatrics
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21. How Do You Confirm Intubation?
• Bilateral & equal breath sounds
• CXR confirmation
- If decreased on one side?
• Absent sounds over stomach
- If absent on one side and
hypertympanic
• Improvement of oxygenation
• Mist in ETT during bagventilation
- If saturations rapidly decrease?
•EtCO2 confirmation
- Colorimetric: Yellow = Yes
- Waveform analysis/quantitative: >
15 mm Hg
Pediatrics
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22. 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?
Pediatrics
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23. Potential Complications of Oral
Intubation
•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)
Pediatrics
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24. Pneumothorax
From: Lee et al. Korean J Anesthesiol 2010 (Left); www.ambu.com (Right)
Pediatrics
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25. Dental Trauma (DON’T DO THIS)
From: Windsor and Lockie. Anaesth and Int Care Med. 2008
Pediatrics
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