Intubation (peds)
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
- 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
- Sedation
- 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
- Rocuronium 1.2mg/kg
See Also
Pediatric Critical Care
- Critical care quick reference
- Neonatal resuscitation
- Newborn resuscitation
- PALS (Main)
- Intubation (peds)
- Initial mechanical ventilation settings (peds)
- Vital signs (peds)
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
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
- ↑ Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles Airway Card
- ↑ 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
- ↑ Tsou CH, Chiang CE, Kao T, et al. Atropine-triggered idiopathic ventricular tachycardia in an asymptomatic pediatric patient. Can J Anaesth 2004; 51:856
- ↑ Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care 2004; 20:651
- ↑ 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.
- ↑ https://pedemmorsels.com/cuffed-endotracheal-tubes-in-children/
- ↑ 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.
- ↑ https://pedemmorsels.com/atropine-needed-rsi/
- ↑ https://reference.medscape.com/drug/ketalar-ketamine-343099