Endotracheal Intubation




INDICATIONS



Listen






  • 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



Listen






  • Bradycardia



  • Hypoxemia/desaturation



  • Hypotension



  • Inability to intubate





EQUIPMENT-SEE FIGURES 6-1 AND 6-2



Listen






  • 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





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



Listen




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



See Table 6-2




TABLE 6-2

Proposed Intubation Checklist Items





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