Intubation (peds): Difference between revisions

(Created page with "==Airway Adjuncts== OP Airway Size: from lip/teeth to angle of jaw NP Airway: tip of nose to tragus BVM in Kids: 10cc/kg ==ETT== ETT Size: (Age/4) + 4 Pree...")
 
 
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{{Peds top}} [[intubation]]. ''See [[critical care quick reference]] for pre-calculated airway sizes by weight.''
==Airway Adjuncts==
==Airway Adjuncts==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Airway'''
| align="center" style="background:#f0f0f0;"|'''Placement'''
|-
| '''Naso'''pharyngeal||Tip of nose to tragus
|-
| '''Oro'''pharyngeal||From lip/teeth to angle of jaw
|-
| [[Bag valve mask]]||10cc/kg
|}


'''LMA size''' = Wt(kg)/20 + 1


OP Airway Size:
==Pediatric Airway Equipment Sizes==
 
===Los Angeles Airway Card<ref>Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles Airway Card</ref>===
from lip/teeth to angle of jaw
{| {{table}}
 
| align="center" style="background:#f0f0f0;"|'''Age'''
| align="center" style="background:#f0f0f0;"|'''Weight (kg)'''
 
| align="center" style="background:#f0f0f0;"|'''Cuffless'''
NP Airway:
| align="center" style="background:#f0f0f0;"|'''Cuffed'''
 
| align="center" style="background:#f0f0f0;"|'''Depth (cm)'''
tip of nose to tragus
| align="center" style="background:#f0f0f0;"|'''Miller'''
 
| align="center" style="background:#f0f0f0;"|'''Macintosh'''
| align="center" style="background:#f0f0f0;"|'''LMA Size'''
 
|-
BVM in Kids: 10cc/kg
| Preterm||<1||2.5||-||6 - 7||Miller 00 or 0||-||1
 
|-
| Preterm||1 - 2.5||3.0||-||7 - 9||Miller 0||-||1
 
|-
==ETT==
| Neonate||2.5 - 4||3.0||-||10||Miller 0||-||1
 
|-
 
| 6mo||6 - 7.5||3.5||3.0||10 - 11||1||-||1.5
ETT Size:
|-
 
| 1 year||10||4.0||3.5||12||1||-||1.5
(Age/4) + 4
|-
 
| 2 - 3 y||12 - 14||4.5 - 5.0||4.0 - 4.5||13 - 14||1.5||-||2
|-
 
| 4 - 6 y||16 - 20||5.0 - 5.5||4.5 - 5.0||15 - 16||2||2||2
Preemies:
|-
 
| 7 - 9 y||22 - 26||5.5 - 6.0||5.0 - 5.5||16 - 18||2||2||2.5
1kg 2.5mm tube at 7cm depth
|-
 
| 10 - 12 y||28 - 32||-||6.0 - 6.5||18 - 19||2||3||2.5 - 3
2g 3.0mm tube at 8 cm depth
|-
 
| 13 - 15 y||34 - 38||-||6.5 - 7.0||19 - 20||2||3||3
3kg  3.5 tube at 9 cm depth
|-
 
| 16 - 18 y||>40||-||7.0 - 8.0||21 - 24||2||3||3.5 - 4
|}
 
Cuffed 1/2 size smaller than cuffless
 
 
Depth of Tube Placement: 3 x ETT
 


*Why uncuffed in kids:


because cricoid ring is narrowest portion of the airway...uncuffed up to 6
*Blade Size Estimate
**ETT Size:  (Age/4) + 4 for uncuffed, (Age/4) + 3.5 for cuffed
**Preemie <1.4kg: 00
**Newborn: 0
**Neonate/infant: 1
**2 blade starting at 2 yo
**3 blade in 3rd grade (8-9 yo)


*Endotracheal Cuffed Tube Estimate
**1 yr, 10kg, size 4
**5 yr, 20kg, size 5
**10 yr, 30 kg, size 6


==Other Tubes:==
*Cuffed and uncuffed ETT are acceptable outside neonatal age
*Depth of Tube Placement: 3 x uncuffed ETT size (cm)
**Neonate: Nasal septum to tragus in cm + 1 cm


*[[Atropine|Atropine]]
**While atropine is not routinely recommended for pretreatment before RSI, it has been frequently used for infants younger than one year due to their predilection for bradycardia during RSI. However, rare cases of ventricular tachycardia and fibrillation have been seen in pretreatment of children, hence it is not recommended for this age group.<ref>Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7</ref><ref>Tsou CH, Chiang CE, Kao T, et al. Atropine-triggered idiopathic ventricular tachycardia in an asymptomatic pediatric patient. Can J Anaesth 2004; 51:856</ref><ref>Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care 2004; 20:651</ref>


NG, OG, foley: 2 x ETT
==Relation to Other Tubes==
*NG, OG, foley = 2 x ETT
*Chest Tube (max) = 4 x ETT


==Apneic oxygenation==
*Infant: 5L/min
*Child: 10 L/min
*Adolescent/adult: 15 L/min


Chest Tube (max) 4x ETT
==Endotracheal Drug Delivery==
*Endotracheal Drug Delivery: 1:1000 solution at 0.1mg/kg = 0.1ml/kg<br />
*Newborn: 1:10,000 solution at 0.03mg/kg = 0.3mL/kg




==ETT Drug Delivery==
==Neonatal Considerations==
*Anatomical differences of neonates (compared to adults/big kids):
**Large occiput--> may need shoulder roll to get ear to sternal notch aligned
**Relatively larger tongue, small mouth
**More anterior and superior larynx<ref>Nagler J, Mick NW. Airway Management for the Pediatric Patient. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:(Ch) 161.</ref>
***Glottic opening at level of C1 in infants
***Transitions to C3/4 by age 7 years
***At C5 by adulthood
**Narrowest portion of airway is at cricoid cartilage (as opposed to vocal cords in adults)
**Larger/floppier epiglottis
**Short trachea--> easy to mainstem tube, easy for accidental tube dislodgement


*Cuffed vs uncuffed ETT: controversial<ref>https://pedemmorsels.com/cuffed-endotracheal-tubes-in-children/</ref> but cuffed tubes now genearlly considered acceptable<ref>American Heart Association. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, Vol. 122, Issue 18, Suppl 3; Novemeber 2, 2010.</ref>


Endotracheal Drug Delivery: 1:1000 solution @ 0.1 mg/kg = 0.1ml/kg
# Numbered list item


==Neonatal Intubation==
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Age'''
| align="center" style="background:#f0f0f0;"|'''Weight (kg)'''
| align="center" style="background:#f0f0f0;"|'''Cuffless'''
| align="center" style="background:#f0f0f0;"|'''Cuffed'''
| align="center" style="background:#f0f0f0;"|'''Depth (cm)'''
| align="center" style="background:#f0f0f0;"|'''Blade'''
|-
| Preterm||<1||2.5||-||6-7||Miller 00 or 0
|-
| Preterm||1-2.5||3.0||-||7-9||Miller 0
|-
| Neonate||2.5-4||3.0||-||10||Miller 0
|}


==Source==
*ETT depth
**Newborn/neonate: uncuffed ETT x 3 (cm at lip)
**Preemie: weight in kg +1 (cm at lip)
*LMA size
**Weight in kg/20 + 1
*Apneic O2 by NC for newborn/neonate: 5L/m
*Routine vent settings
**FiO2 100%--> wean
**PEEP 4-5
**TV 8-10cc/kg
**RR 25-35
**I-time 0.5s


==Drugs==
*[[Atropine]] premedication
**Controversial
**Neonates VERY prone to [[PALS: Bradycardia|bradycardia]] with myriad stimuli, including the vagal stimulation of laryngoscopy
**May not be needed routinely but should at least have handy in case of bradycardia<ref>https://pedemmorsels.com/atropine-needed-rsi/</ref>
**0.01-0.03 mg/kg IV/IO


Adapted from Pani, DeBonis
*Sedation
**[[Ketamine]] ''not'' approved for <3mo <ref>https://reference.medscape.com/drug/ketalar-ketamine-343099</ref>
**[[Fentanyl]] 1mcg/kg
**[[Etomidate]] 0.3mg/kg
*[[Neuromuscular blocking agents|Paralytic]] (Consider doubling dose in shock)
**[[Rocuronium]] 1.2mg/kg
***Preferred as may not yet be aware of preexisting conditions that would make sux contraindicated
**[[Succinylcholine]] 1.5mg/kg


==See Also==
{{Pediatric critical care pages}}
{{Related Difficult Airway Pages}}
{{Mechanical ventilation pages}}


==External Links==
*Practical pediatric RSI/vent algorithm: http://pemsource.org/wp-content/uploads/2016/11/RSI-and-Ventilator-Settings-Algorithm.pdf
*Adventures in RSI from Pediatric Emergency Playbook (with preferred agents in different patients) http://pemplaybook.org/podcast/adventures-in-rsi/


==References==
<references/>


[[Category:Peds]]
[[Category:Critical Care]]
[[Category:Pediatrics]]
[[Category:EMS]]
[[Category:Procedures]]

Latest revision as of 17:38, 11 January 2021

This page is for pediatric patients. For adult patients, see: intubation. See critical care quick reference for pre-calculated airway sizes by weight.

Airway Adjuncts

Airway Placement
Nasopharyngeal Tip of nose to tragus
Oropharyngeal From lip/teeth to angle of jaw
Bag valve mask 10cc/kg

LMA size = Wt(kg)/20 + 1

Pediatric Airway Equipment Sizes

Los Angeles Airway Card[1]

Age Weight (kg) Cuffless Cuffed Depth (cm) Miller Macintosh LMA Size
Preterm <1 2.5 - 6 - 7 Miller 00 or 0 - 1
Preterm 1 - 2.5 3.0 - 7 - 9 Miller 0 - 1
Neonate 2.5 - 4 3.0 - 10 Miller 0 - 1
6mo 6 - 7.5 3.5 3.0 10 - 11 1 - 1.5
1 year 10 4.0 3.5 12 1 - 1.5
2 - 3 y 12 - 14 4.5 - 5.0 4.0 - 4.5 13 - 14 1.5 - 2
4 - 6 y 16 - 20 5.0 - 5.5 4.5 - 5.0 15 - 16 2 2 2
7 - 9 y 22 - 26 5.5 - 6.0 5.0 - 5.5 16 - 18 2 2 2.5
10 - 12 y 28 - 32 - 6.0 - 6.5 18 - 19 2 3 2.5 - 3
13 - 15 y 34 - 38 - 6.5 - 7.0 19 - 20 2 3 3
16 - 18 y >40 - 7.0 - 8.0 21 - 24 2 3 3.5 - 4


  • Blade Size Estimate
    • ETT Size: (Age/4) + 4 for uncuffed, (Age/4) + 3.5 for cuffed
    • Preemie <1.4kg: 00
    • Newborn: 0
    • Neonate/infant: 1
    • 2 blade starting at 2 yo
    • 3 blade in 3rd grade (8-9 yo)
  • Endotracheal Cuffed Tube Estimate
    • 1 yr, 10kg, size 4
    • 5 yr, 20kg, size 5
    • 10 yr, 30 kg, size 6
  • Cuffed and uncuffed ETT are acceptable outside neonatal age
  • Depth of Tube Placement: 3 x uncuffed ETT size (cm)
    • Neonate: Nasal septum to tragus in cm + 1 cm
  • Atropine
    • While atropine is not routinely recommended for pretreatment before RSI, it has been frequently used for infants younger than one year due to their predilection for bradycardia during RSI. However, rare cases of ventricular tachycardia and fibrillation have been seen in pretreatment of children, hence it is not recommended for this age group.[2][3][4]

Relation to Other Tubes

  • NG, OG, foley = 2 x ETT
  • Chest Tube (max) = 4 x ETT

Apneic oxygenation

  • Infant: 5L/min
  • Child: 10 L/min
  • Adolescent/adult: 15 L/min

Endotracheal Drug Delivery

  • Endotracheal Drug Delivery: 1:1000 solution at 0.1mg/kg = 0.1ml/kg
  • Newborn: 1:10,000 solution at 0.03mg/kg = 0.3mL/kg


Neonatal Considerations

  • Anatomical differences of neonates (compared to adults/big kids):
    • Large occiput--> may need shoulder roll to get ear to sternal notch aligned
    • Relatively larger tongue, small mouth
    • More anterior and superior larynx[5]
      • Glottic opening at level of C1 in infants
      • Transitions to C3/4 by age 7 years
      • At C5 by adulthood
    • Narrowest portion of airway is at cricoid cartilage (as opposed to vocal cords in adults)
    • Larger/floppier epiglottis
    • Short trachea--> easy to mainstem tube, easy for accidental tube dislodgement
  • Cuffed vs uncuffed ETT: controversial[6] but cuffed tubes now genearlly considered acceptable[7]
  1. Numbered list item

Neonatal Intubation

Age Weight (kg) Cuffless Cuffed Depth (cm) Blade
Preterm <1 2.5 - 6-7 Miller 00 or 0
Preterm 1-2.5 3.0 - 7-9 Miller 0
Neonate 2.5-4 3.0 - 10 Miller 0
  • ETT depth
    • Newborn/neonate: uncuffed ETT x 3 (cm at lip)
    • Preemie: weight in kg +1 (cm at lip)
  • LMA size
    • Weight in kg/20 + 1
  • Apneic O2 by NC for newborn/neonate: 5L/m
  • Routine vent settings
    • FiO2 100%--> wean
    • PEEP 4-5
    • TV 8-10cc/kg
    • RR 25-35
    • I-time 0.5s

Drugs

  • Atropine premedication
    • Controversial
    • Neonates VERY prone to bradycardia with myriad stimuli, including the vagal stimulation of laryngoscopy
    • May not be needed routinely but should at least have handy in case of bradycardia[8]
    • 0.01-0.03 mg/kg IV/IO

See Also

Pediatric Critical Care

Airway Pages

Mechanical Ventilation Pages

External Links

References

  1. Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles Airway Card
  2. Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7
  3. Tsou CH, Chiang CE, Kao T, et al. Atropine-triggered idiopathic ventricular tachycardia in an asymptomatic pediatric patient. Can J Anaesth 2004; 51:856
  4. Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care 2004; 20:651
  5. Nagler J, Mick NW. Airway Management for the Pediatric Patient. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:(Ch) 161.
  6. https://pedemmorsels.com/cuffed-endotracheal-tubes-in-children/
  7. American Heart Association. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, Vol. 122, Issue 18, Suppl 3; Novemeber 2, 2010.
  8. https://pedemmorsels.com/atropine-needed-rsi/
  9. https://reference.medscape.com/drug/ketalar-ketamine-343099