Intubation of the Pediatric Patient

Inadequate oxygenation or ventilation

Airway obstruction

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

Excess work of breathing

Nonresponsive and apneic

CONTRAINDICATIONS

Absolute Contraindications

None for unstable patients (i.e., “crash” airway)

Relative Contraindications

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

Infectious: Epiglottitis, croup, retropharyngeal abscess, bacterial tracheitis

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

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

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

RISKS/CONSENT ISSUES

Airway trauma

Arrhythmia (e.g., bradyarrhythmia)

Aspiration of stomach contents

Esophageal intubation

Increase in blood pressure and intracranial pressure (ICP)

Hypoxemia

Pain

LANDMARKS

Anatomical differences in children (FIGURE 89.1):

Larger tongue

Larger and floppy epiglottis

Narrower cricoid ring

Larger occiput

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

C1 in infancy

C3–C5 at age 7

C4–C6 in the adult (Figure 89.1)

Differences 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.

General Basic Steps

Preparation

Preoxygenation

Pretreatment

Protection and positioning

Paralysis and induction

Placement of tube and proof of tube placement

Postintubation management

TECHNIQUE

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.”

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

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

Size is best estimated using Broselow tape or centimeter measuring tape

Oral airway

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

Nasopharyngeal airway

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

Laryngoscope blade

Straight/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.

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

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

TABLE 89.1.

EQUIPMENT FOR RSI—“SOAP ME” MNEMONIC

S	Suction	Yankaur device (children/adolescents) and/or flexible catheters (infants), suction tubing, wall-mounted suction
O	Oxygen	Face mask (preferably nonrebreather), oxygen tubing, high-flow oxygen source, Bag/Valve device (with positive-pressure valve)
A	Airway	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.
P	Pharmacology	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.
ME	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.

Historically, 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.

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

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

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

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

End-tidal CO₂ monitor

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

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

Preoxygenation

Theoretically, 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.