Pediatric Intubation
While cliché, nowhere is the old adage “kids aren't just little adults” more true than in the management of emergent pediatric airways. Both anatomically and physiologically unique, not only from adults, but also from age to age, pediatric airways require forethought and planning in order to provide appropriate care - Kyle Yoder MD
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Intubating The Infant or Toddler
Providers who infrequently care for children less than two years of age are often rightfully anxious when faced with a sick child, especially if airway management is required. This is especially true if the child is less than one. Healthy respect is certainly indicated because airway complications are one of the leading causes of pediatric cardiac arrest.
Children are not small adults. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously morphing until finally reaching the adult form and function. We all know this instinctively. When we look at a child we can often tell how old he or she is simply by looking at head size, characteristics…
Resources
Vortex Airway RESCUE Cart
The Vortex Airway Rescue Cart differs from most conventional airway carts in 3 important ways...
Intubation of the critically unwell child in the emergency department
It is important that the right planning takes place even in an emergency situation. A lot of things need to happen quickly.
Intubation Preparation and Equipment
None of us would dream of sitting an exam or going for an important job interview without preparing. Likewise if you were on an aeroplane and found out the pilot and crew hadn’t performed the routine pre-departure checks you would be outraged and feel that they were taking an unnecessary chance with your life. Likewise with intubation the child and their parents are putting their trust in you to do your best to keep the child safe during a procedure, and if you want to do this to the best of your ability (and why wouldn’t you) you must prepare properly.
Pediatric Airway Management in the Emergency Department
Much of the knowledge and skill set from the adult world is applicable here, however there are several important differences that are unique to the pediatric population.
The Pediatric Airway
Placing a towel roll under the patient's shoulders helps facilitate neck extension and better alignment of the oropharynx and trachea, making anatomic obstruction of the airway less likely and improving success of visualizing the vocal cords on direct laryngoscopy. Gentle thyroid cartilage manipulation may additionally help to bring more anteriorly positioned airways into view.
The Pediatric Airway: Pearls and Pitfalls
One cannot over-emphasize the importance of the appropriate equipment size for children. One size does not fit all. The pediatric age group represents a spectrum from neonates to infants, children, and adolescents.
Airway management in neonates and infants
In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Airway Management in the Pediatric Trauma Patient
Moreover, trauma airways are by definition, difficult airways, and pediatric patients present unique challenges due to changing anatomy and physiology.
Airway Management, pediatric
The basic principles of airway management in children and adults are the same. Remember what patient(s) require is oxygen and not the plastic (as in endotracheal tube). This is an especially important tenet to remember in the 'difficult' pediatric airway.
Difficult to Ventilate and Oxygenate: The Pediatric Airway Overview
There are a number of techniques providers can utilize in order to optimize first-pass intubation rates. Placing a towel underneath the shoulders and using the head tilt-chin lift maneuver can overcome the neck flexion caused by the larger occiput, resulting in better oropharyngeal and laryngeal alignment, and reduce airway obstruction.
Elemental EM: Pediatric Intubation
Although one can feel there is never enough “practice” at intubation, pediatric intubation is even more rare.
Endotracheal Tube Depth
One of the most important aspects of endotracheal intubation is proper positioning of the ETT.
How Much Does a Shoulder Roll (or Equivalent) Help Pediatric Intubation?
We admit that we’ve made the mistake of complicating a pediatric intubation by not using a shoulder roll (or an equivalent means of elevating a child’s shoulders). But how much does it really matter? Two separate studies in 2019 alone re-emphasize the importance.
Mainstem Intubation In Pediatric Patients: How To Avoid It
A variety of techniques for determining and/or confirming endotracheal tube position exist. Use of one or more of them is important in children due to their short trachea and increased likelihood of deep intubation. Some, like the confirmatory chest x-ray, are obvious. However, it’s more desirable to apply techniques during the intubation in order to avoid deep intubation in the first place.
Paediatric Rapid Sequence Intubation
This may be difficult with an uncooperative child, a cautious dose of fentanyl 0.25mcg/kg IV provides a slightly sedated more compliant child, however caution needs to be taken as airway protection must be maintained, not normally a problem for small children, but older ones may kick up a fuss
Pediatric Rapid Sequence Intubation: An In-depth Review
Recently updated Pediatric Advanced Life Support (PALS) guidelines recommend the use of cuffed endotracheal tubes for all ages except the newborn period.
The Pediatric Airway and Rapid Sequence Intubation in Trauma
The pediatric airway differs greatly from the adult airway: It is shorter and more anterior. This often can make direct visualization challenging.
The Pediatric Airway and Rapid Sequence Intubation in Trauma
Nondepolarizing paralytic agents, such as rocuronium, are increasing in popularity in pediatric emergency medicine because of their shorter half-life and more favorable safety profile.
The Vortex: a universal ‘high-acuity implementation tool' for emergency airway management
Unlike the major algorithms, which are context specific, the Vortex is flexible enough for the same tool to be applied to any circumstance in which airway management takes place, independent of context, patient type, or the intended airway device. This makes the same tool suitable for use by emergency physicians, intensivists, paramedical staff, and anaesthetists.
Intubating The Infant or Toddler
Intubating an infant or small child is more of a challenge than an older child or adult both because of their anatomical differences as well as their physiologic predisposition for hypoxia.
10 Common Pediatric Airway Problems—And Their Solutions
There is good reason why most providers are anxious about taking care of children, especially infants and children less than 2 years of age. It is challenging and intimidating to open the airway of such a small infant when adult-sized fingers dwarf the size of the baby’s mouth and all of the instruments are smaller.
PeDI Registry
Pediatric Difficult Intubation (PeDI) Registry group is a multicenter organization dedicated to assessing, understanding and improving the outcomes of children with Difficult Direct Laryngoscopy (DDL) to facilitate benchmarking, quality improvement and research
The Vortex Approach
While technical competence and adequate planning are crucial to effective airway management, it is well recognised that even well prepared airway clinicians can sometimes fail to perform basic interventions under stress. Completion of a 'best effort' at any of the three upper airway lifelines without being able to restore alveolar oxygen delivery mandates spiral movement inward towards the next lifeline. The circular arrangement of the three lifelines on the tool means that airway management can be initiated using any lifeline and proceed to the remaining ones in whatever sequence is judged most appropriate in the clinical circumstances.
Pediatric Endotracheal Tube (ETT) Size
Estimates ET tube size based on age.
RSI Drugs
Dosing for specific situations.
WikEM
Intubation peds
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