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Pediatric Intubation
1
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