• Apnea.
• Acute respiratory failure (Pao2 < 50 mm Hg in patient with fraction of inspired oxygen [Fio2] > 0.5 and Paco2 > 55 mm Hg).
• Need to control oxygen delivery (eg, institution of positive end-expiratory pressure [PEEP], accurate delivery of Fio2 > 0.5).
• Need to control ventilation (eg, to decrease work of breathing, to control Paco2, to provide muscle relaxation).
• Inadequate chest wall function (eg, in patient with Guillain-Barré syndrome, poliomyelitis).
• Absence of protective airway reflexes (eg, cough, gag).
• Glasgow Coma Score ≤ 8.
• Suction.
• 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.
• Oxygen.
• Resuscitation bags.
• Masks (appropriate sizes for ventilation).
• Laryngoscope (blade, handle, bulb, battery).
• Endotracheal tubes (appropriate sizes, cuffed, uncuffed).
• Forceps.
• Oropharyngeal airway.
• Tongue blade.
• Bite block.
• Tape (to secure tube).
• Stylet (appropriate sizes).
• CO2 detector device.
• Syringe to inflate the endotracheal tube balloon on cuffed tubes.
• Table 4–1 lists the suggested sizes for endotracheal tubes.
• Uncuffed tubes are generally recommended in children younger than 8 years, except in cases of severe lung disease.
• Laryngoscopes.
• Handle with battery and blade with light source. Adult and pediatric handles fit all blades, and differ only in handle diameter.
• A straight blade provides greater displacement of the tongue into the floor of the mouth and visualization of a cephalad and anterior larynx (Figure 4–1A).
• A curved blade may be used in the older child; the broader base and flange allow easier displacement of the tongue (Figure 4–1B).
• Table 4–2 lists the suggested sizes of blades.
• 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 halothane.
• For difficult intubations, other techniques, such as fiberoptic intubation, may be used.
| Age | Internal Diameter (mm) |
|---|---|
| Premature infant | 2.5–3.0 |
| Newborn | 3.0 |
| Newborn–6 months | 3.5 |
| 6 months–12 months | 3.5–4.0 |
| 12 months–2 years | 4.0–4.5 |
| 3–4 years | 4.5–5.0 |
| 5–6 years | 5.0–5.5 |
| 7–8 years | 5.5–6.0 |
| 9–10 years | 6.0–6.5 |
| 11–12 years | 6.5–7.0 |
| 13–14 years | 7.0–7.5 |
• 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.
• Following are the 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.
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