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Pediatric Intubation

By Natalia Kot, MS3

When to Intubate

  • Respiratory failure

X Oxygenation

  • PaO2 <60 torr on RA
  • PaO2/FiO2 <300 torr
  • A-a gradient of >300

X Ventilation

  • PaCO2 >50 torr w/o chronic hypercapnia
  • Rapidly rising PaCO2 or out of proportion to respiratory effort

When to Intubate

Signs of Distress

Signs of Distress

  • Accessory muscle use/retractions
  • Agitation/AMS
  • Apnea
  • Cyanosis
  • Grunting
  • Head bobbing
  • Inability to lay supine
  • Nasal flaring
  • Prolonged expiration
  • Respiratory muscle fatigue
  • Stridor
  • Sweating
  • Tachycardia
  • Tachypnea
  • Wheezing

Airway Assessment

Airway

Assessment

  • Mallampati Classification
  • NOT very useful in children

  • Issues with:
  • Teeth, tongue, palate, mandible, chin-to-chest, neck extension, facial trauma

Nasal-oropharynx

  • We don't develop our "adult" naso-oropharynx until ~age 8
  • Kids are predominantly nose breathers

Anatomic

Variations

Larynx

  • More anterior & superior in children

Larynx

Trachea

  • Cylinder vs. funnel shaped
  • Glottis vs. subglottis as narrowest point

Trachea

Poiseuille's Law

8/(2^4) = 0.5

Blitz Physics Review

8/(4^4) = 0.03125

Choose Your: Laryngoscope Blade

  • Age 2 & under: STRAIGHT BLADE
  • B/c epiglottis is esp. floppy
  • Tip of blade to end of vallecula + lift; should end up over the epiglottis
  • Also in cervical spine injury @ any age
  • SIZES
  • Less than 1 y.o. ("0 years old") = Size 0
  • 1 y.o. = Size 1
  • 2-12 y.o. = Size 2
  • ≥13 y.o. = Size 3
  • Age 3 & up: CURVED BLADE
  • Easier to displace the large tongue or copious secretions
  • Keep tip @ edge of vallecula
  • SIZES
  • 2-12 y.o. = Size 2
  • ≥13 y.o. = Size 3

Choosing the

Right Equipment

Choose Your: Endotracheal Tube

  • UNCUFFED TUBES allow airway clearance;

do not protect from aspiration

  • Less than 1 y.o. = 3.5-4.0 mm
  • 1 y.o. = 4.0-4.5 mm
  • 2 y.o. & up = (Age/4) + 4

  • CUFFED TUBES allow secretion clearance, protection from aspiration, and PEEP can be more effectively administered to these tubes
  • Less than 1 y.o. = 3.0-3.5 mm
  • 1 y.o. = 3.5 - 4.0 mm
  • 2 y.o. & up = (Age/4) + 3
  • MICROCUFFED = (Age/4) + 3.5
  • Depth
  • Newborn ("0 y.o.") = 10 cm
  • 1 y.o. = 11 cm
  • 2 y.o. = 12 cm
  • Greater than 2 y.o. = (Age/2) + 12

Choose Your: ETT

Review Case

12 yo girl with cerebral palsy has just come out of the OR after a spinal fusion surgery. She was extubated in the OR, but 6 hours postoperatively, she develops tachycardia and hypotension. O2 sat is 82% on nasal cannula, and CXR shows bilateral pleural effusions.

1. Do we intubate?

2. If so, cuffed or uncuffed tube?

3. Size of ET tube?

4. Depth of ET tube?

Review Case

Question #1

She has many risk factors for potential respiratory failure, including the tachycardia, hypotension, and non-reassuring CXR and O2 sat. In addition, she has cerebral palsy, and we know that any neuromuscular disease poses an extra risk of respiratory failure.

Question #1

Question #2

Her neuromuscular disorder also places her at increased risk of aspiration → cuffed tube

Question #2

Question #3

(Age/4) + 3

= (12/4) + 3

= 3+ 3

= 6 mm

Question #3

Question #4

(Age/2) + 12

= (12/2) + 12

= 6 + 12

=18 cm

Question #4

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