8 Intubation and Mechanical Ventilation

Question 1

remarks on intubation in children

Answer 1

The presentation of a critically ill child requiring significant support of oxygenation or ventilation, potentially leading to endotracheal intubation, is relatively uncommon compared to adults.

Question 2

epiglottis in infancy

Answer 2

floppy epiglottis, so lift it directly

many skilled laryngoscopists prefer to use a straight laryngoscope in younger children as it allows the epiglottis to be directly lifeted out of view by the laryngsopce

Question 3

narrowest portion of the pediatric airway

Answer 3

subglottic space
cricoid narrowing

Question 4

partial airway obstruciton in children

Answer 4

The swollen, mobile tissues create a dynamic obstruction, and, in the agitated, crying, young child with subsequent turbulent airflow, the work of breathing can increase 32-fold

This can lead to complete obstruction and respiratory arrest

this principle underscores the need to keep children with partial airway obstructions as calm as possible

Question 5

surgical cricothyrotomy is contraindicated in

Answer 5

children <10 years old because the cricothyroid membrane is too small

therefore, in children <10 years of age, needle cricothyrotomy is the sublottic invasive airway of choice

Question 6

Bag-mask ventilation

Answer 6

BVM is a fundamental critical skill for pediatric resuscitaiton and arguably one of the most important skills to master

Providers should generally squeeze the bag only enough to allow for chest rise in order to prevent gastric insufflation and barotrauma

Question 7

V-E Technique

Answer 7

”V-E” technique or thenar eminence technique
- requires two hands but results in a good seal and potentially ~less hand fatigue~ than other methods
- with either technique, it is critical that the majority of force be dedicated to pulling the airway up into the mask, rather than pushing the mask down into the face

Question 8

how to determine ET size in children

Answer 8

in children >1 y/o:
(age/4) + 4

Question 9

cuffed and uncuffed ET tubes

Answer 9

it is generally recommended that cuffed endotracheal tubes be used down to size 3.5, which would typically be the size for a full-term newborn

Previously, it was taught that uncuffed ET tubes were preferred for smaller tube sizes

however, in many cases, uncuffed tubes result in significant air leaks and can require subsequent replacement, which reexposes the patient to the risks of intubation unnecessarily

Question 10

preferred laryngoscope blade in young children

Answer 10

straight laryngoscope blades (Miller) are preferred to curved blades in young children because the large epiglottis can be lifted directly, and the large tongue is more easily displaced to provide direct visualization

Question 11

how to determine proper blade length

Answer 11

place the blade handle joint at the child’s upper cinsors and the tip at the angle of the mandible.

the length of the blade from its tip to the handle should be within 1 cm proximal or distal of the angle of the mandible

Question 12

Push-dose epi in children

Answer 12

push-dose epi: 1 mcg/kg bolus doses to maintain BP > 70 + (2xage)

Question 13

remarks on cricoid pressure

Answer 13

cricoid pressure may not be needed, because it has been associated with difficulty with intubaiton and BMV, and in children, cricoid pressure can occlude the pliable trachea

Question 14

estimation depth of ET tube placement

Answer 14

depth can be estimated by
* tube internal diameter x 3 = tube depth at the lips
* for example, a 4.0 mm internal diameter tube should be 12 cm at the lips

Question 15

preferred method of intubation in children in the ED

Answer 15

RSI remains the preferred method of intubation in children in the ED and is associated with the highest success and lowest complication rates compared to other methods

Question 16

pretreatment in childen

Answer 16

in children, there is no evidence to support the use of pretreatment agents
* bradycardia in children is typically a sign of hypoxia, which should be corrected
* atropine does not prevent succinylcholine-associated bradycardia and should not be given prophylactically

Question 17

sedation in intubation

Answer 17

Provide adequate sedation and analgesia before the effects of induction and paralysis agents wear off

this is particularly important when rocuronium or other longer-acting muscle relaxants are used, because their duration is often much longer than most induction agents used in RSI

Question 18

cricothyrotomy in pediatrics

Answer 18

the most common indication is the “can’t intubate, can’t ventilate” scenario, which is extremely rare in emergency pediatric airway management

Question 19

Cutting the ET tube

Answer 19

if time allows, precut the endotracheal tube proximally at the 13-cm mark at the endotracheal tube adapter site

uncut tubes allow for excessive “dead space” and are also prone to kinking