Endotracheal Intubation

INDICATIONS

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  • Respiratory

    • Apnea

    • Hypoventilation

    • Severe respiratory distress/respiratory muscle weakness

    • Acute respiratory failure (PaO2 <50 mmHg in patient with FiO2 >0.5 and PaCO2 >55 mmHg acutely)

    • Need to control oxygen delivery (e.g., institution of positive end-expiratory pressure [PEEP], accurate delivery of FiO2 >0.5)

    • Need to control ventilation (e.g., to decrease work of breathing, to control PaCO2, to provide muscle relaxation)

  • Neurologic

    • Inadequate chest wall function (e.g., in patient with Guillain-Barre syndrome, poliomyelitis)

    • Absence of protective airway reflexes (loss of cough, gag)

    • Glasgow Coma Score <8

  • Airway

    • Upper airway obstruction

    • Infectious processes (epiglottis, croup)

    • Trauma to the airway

    • Burns (concern for airway edema)

  • Cardiac

    • Cardiopulmonary failure/arrest

    • Low cardiac output states (reduced oxygen demand/consumption)

  • Other

    • Transport of a patient with potential for respiratory failure

CONTRAINDICATIONS

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  • Absolute

    • Nasotracheal intubation is contraindicated in patients with nasal fractures or basilar skull fractures

  • Relative

    • None

RISKS

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  • Bradycardia

  • Hypoxemia/desaturation

  • Hypotension

  • Inability to intubate

EQUIPMENT-SEE FIGURES 6-1 AND 6-2

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  • Suction – source, catheters; should have a tonsil-tipped suction device or a large-bore suction catheter, as well as a suction catheter of appropriate size that fits into the endotracheal tube (ETT)

  • Oxygen – source

  • Ventilation bags – flow inflating bags and self-inflating bags

  • Masks – appropriate sizes for ventilation

  • Laryngoscope – blade (straight or curved), handle, bulb, battery

    • Handle with battery and blade with light source

    • Adult and pediatric handles fit all blades and differ only in handle diameter

  • Video laryngoscope if available

  • Endotracheal tubes – appropriate sizes, cuffed, uncuffed

  • Forceps

  • Oropharyngeal airway

  • Tongue blade

  • Bite block

  • Tape – to secure tube or tube securement device

  • Stylet – appropriate sizes

  • CO2 detector device – colorimetric detection device or capnography

  • Syringe to inflate the endotracheal tube balloon on cuffed tubes

  • Laryngeal mask airways (LMA) – appropriate sizes

  • Medications (see medication section later)

  • Normal saline or Lactated Ringer’s for fluid resuscitation

FIGURE 6-1

Intubation equipment.

Reproduced with permission from Chapter 27. Oral Endotracheal Intubation. In: Hanson C, III. eds. Procedures in Critical Care New York, NY: McGraw-Hill; 2009.

FIGURE 6-2

Laryngoscope blades and handle. Top: straight blade, middle: curved blade.

Reproduced with permission from Klock A, et al, Airway Management. In: Longnecker DE, et al, eds. Anesthesiology, 3e New York, NY: McGraw-Hill, 2018.

GUIDELINES FOR LARYNGOSCOPE, ETT, SUCTION CATHETERS BASED ON AGE AND WEIGHT – SEE TABLE 6-1

  • Historically, uncuffed tubes were recommended for children <8 years of age; however, current research shows that cuffed tubes are safe in all patients except in the newborn period.

  • If a difficult intubation is anticipated due to altered supraglottic anatomy, absolutely no irreversible anesthetics or muscle relaxants should be administered.

  • Such patients should generally be intubated awake or in the operating room with inhaled anesthetic.

  • For difficult intubations, other techniques, such as fiber-optic intubation, may be used.

TABLE 6-1

Guidelines for Laryngoscope, ETT, and Suction Catheters Based on Age and Weight
ETT size internal diameter (mm) Distance lip to midtrachea (cm) Suction cath (Fr)
Age Wt (kg) Laryngoscope Age (yrs)4+4 3 × ETT size 2 × ETT size
Preterm Infant 2 Miller 0 2.5, 3.0 uncuffed 8 5–6
Term Infant 4 Miller 0–1 3.0, 3.5 uncuffed 9–10 6–8
6 mo 8 Miller 1 3.5, 4.0 uncuffed 10.5–12 8
3.0, 3.5 cuffed
1 yr 10 Miller 1 4.0, 4.5 Uncuffed 12–13.5 8
3.5, 4.0 cuffed
2 yr 12–14 Miller 2 4.5 uncuffed 13.5 8
Macintosh 2 4.0 cuffed
4 yr 16–20 Miller 2 5.5 uncuffed 15 10
Macintosh 2 4.5 cuffed
6 yr 22–28 Miller 2 5.0, 5.5 uncuffed 16.5 10
Macintosh 2 5.0 cuffed
8–12 yr 28–45 Miller 2–3 6.0–7.0 cuffed 18–21 12
Macintosh 2–3
>14 yr 50+ Miller 3 7.0, 8.0 cuffed 21 12
Macintosh 3

DISTINGUISHING FEATURES OF THE INFANT AND CHILD AIRWAY COMPARED WITH ADULTS

  • The larynx is more cephalad.

  • The epiglottis is omega shaped.

  • In children younger than 8 years, the cricoid is the narrowest part of the airway.

  • The infant larynx is one-third the size of the adult larynx.

  • The vocal cords are short and concave.

  • Aligning the mouth, pharynx, and glottis to create a visual field is difficult.

  • The endotracheal tube size relates to the cricoid ring.

  • In children, the lower airways are smaller, have less supporting cartilage, and may easily obstruct.

  • A small reduction in diameter results in a large reduction in the cross-sectional area and therefore increased airway resistance.

PROCEDURE

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Checklists are helpful to ensure all team members are prepared for the procedure.

See Table 6-2

TABLE 6-2

Proposed Intubation Checklist Items
Declaration of Airway Emergency Example: “Sats are coming down. The patient is not responding. We are going to have to intubate. Nurse, can you get all of our intubation supplies ready?”
Verbalization of Team Roles

1. Drawing up medications (nurse/pharmacist)

2. Administering medications (nurse)

3. Preparing airway equipment (respiratory therapist)

4. Managing the airway (physician/advanced practice nurse)

Patient Information

Age and weight

Allergies

Last time patient has eaten

Airway abnormalities

Intubation Equipment

Endotracheal tube (ETT) size: cuffed versus uncuffed

Stylet

Laryngoscope – blade and handle

Bag and appropriate size mask attached to oxygen

Suction

Oropharyngeal airway

Syringe (to inflate cuff)

Tape (to secure tube) or tube securement device

Patient monitoring/access

Reliable IV access

Electrocardiogram (ECG) monitor

Noninvasive blood pressure (NIBP) monitoring system

Pulse oximeter (SpO2)

CO2 detector device

Medication(s)

Medication generic and trade name(s)

Medication dosage(s)

PATIENT PREPARATION

  • Preoxygenate with 100% FiO2.

  • In an older child, explain each step as it is done.

PATIENT POSITIONING

  • A neutral “sniffing” position without hyperextension of the neck is usually appropriate for infants and toddlers.

  • Avoid extreme hyperextension in infants, because it may produce airway obstruction.

  • It is sometimes helpful to place a towel under the patient’s shoulders.

  • In patients with head or neck injuries, the neck must be maintained in a neutral position.

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Related posts:

  1. Palliative Care
  2. Anti-infective Agents
  3. Hypertension
  4. Mechanical Ventilation

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Jan 14, 2019 | Posted by in PEDIATRICS | Comments Off on Endotracheal Intubation

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