Pediatric Pearls: Intubation

PEDIATRIC INTUBATION

By: Dr. Lani Mendelson PGY3

HOW DO PEDIATRIC AIRWAYS DIFFER FROM ADULT AIRWAYS?

  1. Airway diameter = smaller
    1. Small diameter of airways results in higher resistance to air flow and increased chance of airway obstruction
    2. Airway edema results in proportionately greater obstruction
  2. Mandible = smaller
  3. Head = larger
  4. Neck = already in flexed position so add towels under shoulder to bring neck in neutral position
  5. Tongue = larger in comparison to head
  6. Larynx = funnel shaped larynx with anterior angulation
  7. Epiglottis = long, floppy, and u-shaped
  8. Vocal cords = angled, pink not white (harder to spot)
  9. Cricoid cartilage = narrowest portion, rather than the vocal cords
  10. Trachea = highly compliant (risks ‘kinking’)
    1. Short and in line with right bronchus

LARYNGOSCOPE SIZE

AGE SIZE
Premie/newborn Miller 0
1 month – 2 years Miller 1 or 1.5
3-6 years Miller 2, Mac 1
6-12 years Miller 2, Mac 2-3
>12 years Mac 3

*The Miller is recommended due to the more anterior airway and the floppy epiglottis of the child and infant. For a child older than 6 years of age, both Mac and Miller can be used.

ENDOTRACHEAL TUBE SIZE

Uncuffed ETT = (AGE/4) + 4

Cuffed ETT = (AGE/4) + 3.5

*If in doubt, use a tube that fits through the nose

*Premie size 3, newborn size 3.5

ENDOTRACHEAL TUBE DEPTH

ETT size x 3

AGE/2 + 12

MEDICATIONS

Atropine – not routinely recommended

  • Infants and children can develop bradycardia from medication effects (especially succinylcholine), vagal stimulation of the hypopharynx/epiglottis, and hypoxia
  • Should be considered in:
    • 1) all patients <1 year of age
    • 2) children <5 years of age receiving succinylcholine
    • 3) adolescents receiving a second dose of succinylcholine (max does 1mg)
    • 4) patients who are experiencing bradycardia prior to intubation
  • Atropine should be given 1-2 minutes prior to any sedative or paralytic agent

Etomidate

  • Sedative used most commonly for patients with hypotension or head trauma
  • Risks: adrenocortical suppression hence consider a different agent in sepsis

Ketamine

  • Sedative used most commonly for patients with hypotension or severe asthma
  • Risks: tachycardia, hypertension, laryngospasm, and excessive salivation

Propofol

  • Sedative for status epilepticus or head trauma/increased intracranial pressure
  • Not recommended for < 3 years old secondary to decreased clearance
  • Risks: hypotension

Benzodiazepines

  • Sedative for status epilepticus
  • Risks: hypotension

Succinylcholine

  • Shorter duration of action
  • Risks: Higher risk of malignant hyperthermia compared to other paralytics, hyperkalemia, congenital neuromuscular disorders

Rocuronium

  • Longer duration of action

Benzodiazepines (midazolam, lorazepam), ketamine, dexmedetomidine, propofol, and opiates (fentanyl, morphine) are commonly used for post-intubation sedation/analgesia regimens

 

GO BACK TO THE BASICS. REMEMBER TO HAVE ALL YOUR BACK UPS READY.

  1. Positioning
  • Remember necks tend to be flexed in neutral flat position (especially in those <8 yrs)
  • Place towel or sheet beneath shoulders to align external auditory canal with sternal notch
  1. Have nasal and oral airways of the appropriate size ready
  2. Pre-oxygenation
  • Same as adults. Use your nasal cannula for apneic oxygenation. Use NRB if needed as well.
  • Would be amazing if have high flow nasal cannula available throughout intubation to prevent desaturations and prolong safe apneic times, but this is not a requirement
  • May need to give some slight sedation for a fussy child with versed or Ativan to allow for pre-oxygenation
  1. Have suction ready
  2. Have BVM ready with the right size mask
  • Jaw thrust can help with displacing the tongue along with aligning airways
  1. If you can’t remember dosing, remember the Broselow Tape
  2. Can’t see the cords, you may have inserted the blade or scope too far, pull back slowly; also remember they maybe pink and not white so harder to identify
  3. Post-intubation remember to ensure tube is not too deep
  • Confirm using color change, bilateral breath sounds, US, CXR

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