22.9c Pediatric Intubation

Pediatric airway emergencies generally produce more anxiety than adult emergencies among both medical care practitioners and families, although many airway procedures can be easier to perform in this patient population.

Historically, EMS practitioners have separated the parents and the child during resuscitation and critical procedures, but recent experience in the emergency department has shown it to be beneficial to have parents present.

As difficult as it can be for the practitioners, children who are conscious usually benefit from having their parents present, and parents benefit from seeing all of the efforts made to save their children even if these efforts are unsuccessful.

The final decision on separation must be made on a case-by-case basis by individual EMS practitioners following local clinical guidelines and customs (Figure 22-107).

A randomized controlled study in a large urban area comparing non–medication-facilitated intubation in children with BVM ventilation showed no improvement in outcomes with intubation over outcomes with BVM ventilation.

Recent evidence also shows that extraglottic airway devices can be very effective in children.

Success rates with them are the same across age groups while intubation success is lower in younger ages, suggesting a benefit in using an extraglottic device in pediatric patients.

For now, the decision on whether pediatric intubation is part of the advanced EMS scope of practice, and in what circumstances, is determined locally.

The airway structures in children are proportionally smaller and more flexible than an adult’s.

Inserting any tube or device into a child’s nose often causes trauma and bleeding because of the size and the presence of enlarged adenoid tissues.

Nasal pharyngeal airways are generally too large to be useful in the child.

Because a child’s cricoid is less rigid than an adult’s, aggressive cricoid pressure can compress the cricoid and obstruct the airway.

Surgical airway use is restricted to patients older than 8 to 10 years.

Selecting the appropriate tube diameter for children is critical.

Too large a tube can cause tracheal edema and/or damage to the vocal cords whereas a tube that is too small la tube may not allow exchange of adequate ventilatory volumes.

Table 22-9 lists general guidelines for selecting ETT size according to a child’s age, and many tables or devices based on the child’s age, weight, or length are available.

Another guide for children’s sizes is this formula: ETT size (mm) = (Age in years + 16) / 4.

The correct tube size for an 8-year-old, for instance, would be , or 6 mm.

You can also determine correct tube size by matching the diameter of the child’s smallest finger.

The depth of insertion of the distal tip for pediatric endotracheal tubes should be 2 to 3 cm below the vocal cords because deeper insertion can result in mainstem intubation or injury to the carina.

The uncuffed ETT has a black glottic marker at its distal end that should be placed at the level of the vocal cords.

The cuffed ETT should be placed so that the cuff is just below the vocal cords.

For detailed guidelines regarding both ETT size, type, depth of insertion, and blade size for different age groups, refer again to Table 22-9.

Infants often require a towel roll behind the shoulders to maintain alignment for an open airway in contrast to older children and adults who may require a towel roll behind the head.

A straight blade is usually preferred initially to control the epiglottis.

An introducer may be useful if the glottis cannot be viewed.

The tongue is larger in relation to the oropharynx than in an adult.

A curved blade may be useful in controlling the tongue during intubation.

The glottic opening is higher and more anterior in the neck than in an adult.

Thus, it is easy to place the blade and tube too deep.

ELM is useful to bring the glottis into view.

The narrowest part of the airway is the cricoid cartilage, not the glottic opening as in adults.

Uncuffed tubes were traditionally mandated on the theory that the narrow cricoid in pediatric patients made the cuff unnecessary, although many clinical guidelines have changed, and cuffed tubes are being used more commonly.

For now, most EMS services are still using uncuffed tubes for pediatric patients under the age of 8 years.

Infants and children are much more prone than adults to bradycardia with hypotension during airway management caused by hypoxemia or direct stimulation with the laryngoscope or from succinylcholine.

To prevent this complication, avoid long intubation attempts and be as gentle as possible during laryngoscopy.

You must monitor heart rate throughout the procedure and stop the procedure to provide 100 percent oxygen by BVM ventilation or extraglottic airway device if the heart rate falls below 60 beats per minute in a child or below 80 beats per minute in an infant.

You should also be prepared to give atropine (0.02 mg/kg, 0.1 mg minimum) by IV bolus, although this is never a substitute for oxygenation.

Children are more prone than adults to a rapid decrease in oxygen saturation during intubation attempts.

Ensuring adequate preoxygenation, keeping intubation attempts short, and moving early to an extraglottic device are helpful precautions.