Respiratory

• • 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).

Neurologic

• • Inadequate chest wall function (eg, in patient with Guillain-Barré syndrome, poliomyelitis).

  • Absence of protective airway reflexes (eg, cough, gag).

  • Glasgow Coma Score ≤ 8.

Airway

• • Upper airway obstruction.

  • Infectious processes (eg, epiglottis, croup).

  • Trauma to the airway.

  • Burns (concern for airway edema).

Absolute

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

• • 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.

• • Desaturation.

  • Bradycardia.

  • Inability to intubate.

  • Tracheal tear or rupture.

• • 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.

• • 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.

• • 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.