Intubation of the Pediatric Patient

imagesInadequate oxygenation or ventilation

imagesAirway obstruction

imagesLoss of protective airway reflexes (e.g., depressed cough and gag reflexes)

imagesExcess work of breathing

imagesNonresponsive and apneic


imagesAbsolute Contraindications

   imagesNone for unstable patients (i.e., “crash” airway)

imagesRelative Contraindications

   imagesIn these circumstances one should consider consultation with anesthesiologist/intensivist, alternative techniques, and/or sedation without paralysis

      imagesInfectious: Epiglottitis, croup, retropharyngeal abscess, bacterial tracheitis

      imagesNoninfectious: Anaphylaxis/angioedema, foreign body, trauma, burns

      imagesCongenital anomalies (e.g., cleft palate, micrognathia)

      imagesUnanticipated difficult airway (e.g., multiple failed attempts)


imagesAirway trauma

imagesArrhythmia (e.g., bradyarrhythmia)

imagesAspiration of stomach contents

imagesEsophageal intubation

imagesIncrease in blood pressure and intracranial pressure (ICP)




imagesAnatomical differences in children (FIGURE 89.1):

   imagesLarger tongue

   imagesLarger and floppy epiglottis

   imagesNarrower cricoid ring

   imagesLarger occiput

   imagesThe glottic opening is more cranial and anterior in children and is located at:

      imagesC1 in infancy

      imagesC3–C5 at age 7

      imagesC4–C6 in the adult (Figure 89.1)

   imagesDifferences are most pronounced under 2 years, transition from 2 to 8 years, then approach small adult anatomy by 8 years


FIGURE 89.1 The anatomic differences particular to children are (a) higher, more anterior position of the glottic opening (note the relationship of the vocal cords to the chin/neck junction); (b) relatively larger tongue in the infant, which lies between the mouth and the glottic opening; (c) relatively larger and more floppy epiglottis in the child; (d) the cricoid ring is the narrowest portion of the pediatric airway versus the vocal cords in the adult; (e) position and size of the cricothyroid membrane in the infant; (f) sharper, more difficult angle for blind nasotracheal intubation; (g) larger relative size of the occiput in the infant.

imagesGeneral Basic Steps




   imagesProtection and positioning

   imagesParalysis and induction

   imagesPlacement of tube and proof of tube placement

   imagesPostintubation management


If crash airway and difficult airway algorithms are not indicated, then rapid sequence intubation (RSI) is the preferred approach. This approach is summarized in seven discrete steps, each beginning with the letter “P.”

imagesPreparation: Directed history, physical examination, indications/contraindications for RSI

   imagesAssemble equipment using the “SOAP ME” mnemonic (TABLE 89.1)

   imagesSize is best estimated using Broselow tape or centimeter measuring tape

      imagesOral airway

        imagesSize using Broselow tape or distance from the angle of the mouth to the ear tragus

      imagesNasopharyngeal airway

        imagesSize using Broselow tape, distance from the tip of the nose to the ear tragus, or largest comfortable size that does not produce skin blanching

      imagesLaryngoscope blade

        imagesStraight/Miller blade traditionally has been preferred to the curved blade for infants and young children. However, either blade can be used in any age group depending on availability and operator comfort.

      imagesEndotracheal tube (ETT) size based on Broselow tape or calculated as follows:

        imagesUncuffed: (Age in years/4) + 4 (subtract 0.5−1 for cuffed tube)

TABLE 89.1.




Yankaur device (children/adolescents) and/or flexible catheters (infants), suction tubing, wall-mounted suction



Face mask (preferably nonrebreather), oxygen tubing, high-flow oxygen source, Bag/Valve device (with positive-pressure valve)



Laryngoscope handle with functional light source and blades, endotracheal tubes, airway tape, stylets, oral/nasopharyngeal airways of varying sizes. Rescue equipment (e.g., Bougie, GlideScope, LMA, cricothyrotomy kit, etc.) should be available in case RSI fails.



Weight-based medications should be prepared in advanced. Agent selection will depend on circumstances and may include sedatives, induction agents, neuromuscular-blocking agents, lidocaine, and atropine.


Monitoring equipment

Cardiorespiratory monitoring with pulse oximetry and frequent blood pressure checks through postintubation monitoring phase. Following endotracheal tube placement, secondary confirmation with end-tidal CO2 calorimeter (qualitative/semiquantitative) and/or capnography (quantitative)

LMA, laryngeal mask airway; RSI, rapid sequence intubation.

        imagesHistorically, uncuffed tubes were preferred in infants and young children due to high rates of subglottic stenosis. Currently, either tube may be used in any age group if leak pressures are monitored.

        imagesPrepare extra tubes, both 0.5 size smaller and larger than estimated

      imagesA stylet can be used to provide rigidity (TABLE 89.2)

      imagesETT depth by Broselow tape or calculated (if age >1 year)

        imagesFormula (in cm): (Age in years/2) + 10 or Tube size × 3

      imagesEnd-tidal CO2 monitor

        imagesIf weight <15 kg, use pediatric calorimeter to avoid false negative readings

      imagesHave airway alternatives available (e.g., GlideScope, Airtraq, laryngeal mask airway [LMA], Bougie, needle cricothyrotomy equipment)


   imagesTheoretically, deliver 100% oxygen for 3 minutes. Practically, use nonrebreather facemask (with positive end-expiratory pressure [PEEP] valve) and high-flow nasal cannula once RSI is considered.

   imagesIf child becomes apneic, use bag valve mask (BVM) ventilation prior to intubation

      imagesPerform neck extension and E-C clamp technique with bag-mask ventilation (BMV) if C-spine injury is not suspected

      imagesIf two providers are available, one person maintains mask seal while the other compresses the bag

      imagesUse the rhythm “squeeze, release, release” to allow time for exhalation

      imagesInsert an oral airway in an unconscious patient who is difficult to ventilate

imagesPretreatment: Refers to the administration of medications to attenuate the potential adverse effects of intubation (TABLE 89.3)

   imagesPrior recommendations summarized by “LOAD” (Lidocaine, Opioid, Atropine, Defasciculating agent)

   imagesNo pretreatment agent is recommended routinely for pediatric RSI

   imagesLidocaine: May limit further rise in ICP in cases of head trauma or elevated ICP

      imagesNo data to suggest or refute use to prevent reflex bronchospasm

   imagesFentanyl: Analgesic effects may decrease the reflex sympathetic response

      imagesMay cause hypotension or respiratory depression with other sedatives

   imagesAtropine: Used for its anticholinergic effects to prevent or treat bradyarrhythmias

      imagesAntisialogogue effect is delayed, limiting its use in RSI

      imagesInterferes with pupillary response of the neurologic examination after paralysis

   imagesDefasciculating agent: “Defasciculating” and “Priming” doses are no longer recommended

TABLE 89.2.



Only gold members can continue reading. Log In or Register to continue

Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Intubation of the Pediatric Patient
Premium Wordpress Themes by UFO Themes