Pediatric Airway Readiness Notes

Overview

• Focus on pediatric airway management considering:
  • Anatomic differences
  • Equipment needed
  • Proper positioning
  • Techniques for intubation

Anatomic Differences

• Infants and Children have unique anatomical features that require careful consideration during airway management.
  • Large Occiput:
  • Flexion of the neck when supine can lead to upper airway obstruction.
  • Suboptimal view for intubation when lying flat.
  • Management: Use a shoulder roll for infants to optimize positioning.
  • Large Tongue:
  • Results in increased risk of airway obstruction.
  • Management: Utilize an oral airway, especially during Bag-Valve-Mask (BVM) ventilation.
  • Longer Epiglottis:
  • Can obstruct view of the vocal cords.
  • Management: Use a Miller blade for intubation in children under 3-4 years.

Key Point #1

• Unique pediatric anatomy requires different positioning and techniques for intubation compared to adults.

Equipment Overview

• Selection of equipment is crucial for effective airway management:
  • Endotracheal Tube (ETT) Size Calculation:
  • Formula: $ETT ext{ size} = \frac{ ext{Age}}{4} + 4$ (for uncuffed tubes)
  • Subtract 0.5 for cuffed tubes.
  • ETT Depth:
  • Formula: $ETT ext{ depth} = 3 imes ext{uncuffed ETT size}$
  • Nasal/Oral/Foley Catheter Size:
  • $NG/OG/Foley = 2 imes ext{uncuffed ETT size}$
  • Chest Tube Size:
  • $Chest ext{ tube} = 3-4 imes ext{uncuffed ETT size}$
  • Blade Sizes:
  • Miller blades recommended for younger children (e.g., Miller 0 for < 1 mo, etc.).

Bag-Valve-Mask (BVM) Ventilation

• Key Point #2: Proper BVM technique can prevent pediatric airway disasters.
• BVM Equipment:
  • Essential items: suction, airway adjuncts, BVM.
  • Correct positioning of BVM is crucial:
  • Correct: Covers mouth, nose, chin, avoiding eyes.
  • Incorrect: Too large (covers eyes) or too small (does not fit well).
• General Tips:
  • Use an oral airway.
  • Avoid pressure on submandibular tissues and eyes.
  • Decompress stomach if necessary.

Pediatric Endotracheal Intubation: Basic Steps

1. Gather necessary equipment and medications.
2. Position patient appropriately.
3. Pre-oxygenate.
4. Intubate using the following steps:
   • Find airway landmarks (Uvula → Epiglottis → Glottic Opening).
   • Optimize the view (control epiglottis, use laryngeal manipulation if needed).
   • Pass ETT into the glottic opening.

RSI Medications

• Induction Agents:
  • Etomidate: $0.3 ext{ mg/kg}$
  • Ketamine: $1.5 ext{ mg/kg}$
  • Fentanyl/Versed: $1 ext{ mg/kg} / 0.1 ext{ mg/kg}$
• Paralytic: Rocuronium: $1 ext{ mg/kg}$
  • Atropine may be considered in reversed situations, $0.02 ext{ mg/kg}$.

Positioning Goals for Intubation

• Important to achieve proper alignment during intubation:
  1. Ensure ear is aligned to the sternal notch.
  2. Glabella is aligned to the chin.