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
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
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.
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 |
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.
Checklists are helpful to ensure all team members are prepared for the procedure.
See 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) |
Preoxygenate with 100% FiO2.
In an older child, explain each step as it is done.
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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