3. Outline
Indications
How are kids different
What to know before you intubate
The set up
What drugs
How to perform
Scenarios
4. Indications for Intubation
Primary respiratory disorder
– Severe hypoxemia (pneumonia, ARDS)
PaO2 <60 mmHg on 60% FiO2
– Severe hypoventilation (bronchiolitis, emphysema, CLD)
PaCO2 >50 mmHg occurring in an acute manner
Primary neuromuscular disorder
– Myopathy (DMD, SMA)
– Altered mental status with hypoventilation (TBI, intoxication)
– Lack of airway protection (TBI, severe HIE, intoxication)
– Need for sedation with risk of airway protection or ventilation
Tight control of paCO2 or pH
– Severe increased ICP (paCO2)
– Severe pulmonary hypertension (pH)
To reduce metabolic demands in severe shock
5. How Are Kids Different
Airway positioning
Larger tongue
Angled vocal cords
Differently shaped epiglottis
Funneled shaped larynx with differing narrowmost
point
15. Look
Look for normal
face and anatomy
– Pierre Robin,
Treacher Collins,
Achondroplasia,
Cleft lip/palate,
Down Syndrome,
Crouzon,
Goldenhar, Apert,
Mucopolysaccari
dosis
– Tumors, trauma
– “Buck teeth,”
missing teeth,
obesity, cervical
immobility
Pierre Robin S.
Down S.
Achondroplasia
Crouzon S.
Treacher Collins S.
Goldenhar S.
Apert S.
Mucopolysaccaridosis
16. Evaluate 3-3-2
3 finger breadths of mouth opening
3 finger breadths submental to hyoid
2 finger breadths hyoid to thyroid
20. LEMON’s
LEMON is nearly 100% predictive of a difficult airway
in adults
– However, it has not been validated completely in kids
– Look
Short neck, large tongue, micrognathia
– Evaluate 3-3-2
3 finger breadths of mouth opening
2 finger breadths submental to hyoid (potential displacement
area)
2 finger breadths hyoid to thyroid
– Mallampati
– Obstruction
– Neck mobility
24. The Blade
Miller
Thinner, straight blade
Miller blade is preferred for
infants and younger children
Facilitates lifting of the
epiglottis and exposing the
glottic opening
Placed on top of epiglottis
lifting away
Possibly better control of
tongue
Mac
Wider, curved blade
Mac tends to be used for
older children and adults
Curves around tongue
Placed into vallecula and lift
away
Possibly wider glottic
opening
25. Generalities
Miller #1 for children < 1 year
Macintosh #2 for children 1-
10 years
Macintosh #3 for children 11-
18 years
26. How Big and How Deep
ETT size
– Uncuffed: 4 + (Age
(yrs)/4)
– Cuffed: 3 + (Age/4)
– (16 + Age)/4
ETT Depth:
– ETT size * 3
– (Age/2) + 12
27. Cuff Vs Uncuff
Old School:
– Uncuff for under 8yo to help prevent subglottic stenosis
and avoid post-extubation stridor
– Deakers et al. J Peds1994 study of 188 kids (95 uncuff,
93 cuff) showed no difference in post-extubation stridor
– Newth et al. J Peds 2004 study of 387 kids showed no
difference in use of racemic post extubation
Current teaching:
– Cuffed tubes universally preferred
– Enables better oxygenation/ventilation
– Better for severe lung disease
30. Pretreatment
Lidocaine:
– Blunts rise in ICP with laryngoscopy
– No good data on validity of claim
– Rx: 1-2mg/kg
Atropine:
– Thought to blunt vagal response and prevent bradycardia;
also helps with secretions
– No good data
– Not necessarily recommended but often used in very young
children
– Rx: 0.02mg/kg with no min dose any more
Glycopyrrolate:
– Can dry secretions some and give a slight increase to HR
– Rx: 5mcg/kg
31. Put to Sleep
Etomidate
Propofol
Ketamine
Fentanyl/versed
32. Etomidate
Non narcotic, non barbiturate sedative
Fast, reliable, hemodynamically stable
Decreases cerebral blood flow and metabolic oxygen
demand lowering ICP
Can cause adrenal suppression with a single dose
Can cause myoclonic jerks/hiccups
Rx:
– 0.3mg/kg
– Works in 15-30 seconds
Who:
– Hemodynamically unstable pts without sepsis (heart pts, ICP
pts)
33. Propofol
Alkphenol sedative hypnotic
Fast acting and easily titratable
Decreases cerebral metabolic oxygen demand and
lowers ICP
Antiepileptic and antiemetic properties
Can lower BP
Rx:
– 1-4 mg/kg
– Works in 30-60 seconds
Who:
– Pts with ICP issues, many respiratory pts, elective
intubations for AMS
34. Ketamine
PCP derivative that provides analgesia, anesthesia and
amnesia
Minimal respiratory depression and hemodynamically
stable
Bronchodilation
Can increase cerebral metabolic oxygen demand and ICP
Causes increased secretions and emergence phenomenon
Can cause laryngospasm
Rx:
– 1-2mg/kg
– Works in 1-2 min
Who:
– Asthma, potentially hemodynamically unstable pts
35. Fentanyl/Versed
Opioid and benzo combination
Analgesia, amnesia and anesthesia
Dose dependent respiratory depression
Minimal hemodynamic instability
Nearly universally applicable
Wider therapeutic window with less consistent sedation
Rx
– Fentanyl 2-4 mcg/kg over 2 min to avoid rigid chest
– Versed 0.1 mg/kg
Who:
– Most anyone
36. Succinylcholine
Depolarizing muscle relaxant
Potent, reliable and fast acting with quick offset
Good for rapid sequence intubation
Contraindicated in hyperkalemia, burns, trauma, increased
IOP, likely ICP, mitochondrial and neuromuscular kids
Rx:
– 1-2 mg/kg
– Onset 60 seconds and lasts 5‐10 minutes
Who:
– Most people unless contraindicated
37. Vecuronium
Nondepolarizing muscle relaxant
No contraindications
Works rapidly
Rx:
– 0.1mg/kg
– Onset in 90-120 seconds and lasts 15-60 min
Who:
– Most anyone
– Can stay around in renal failure patients
38. Rocuronium
Nondepolarizing muscle relaxant
No contraindications
Works rapidly
Rx:
– 0.6-1.2mg/kg (1mg/kg for ease)
– Onset is 60 seconds and lasts 20-40 min
Who:
– Most anyone
39. Cisatracurium
Nondepolarizing muscle relaxant
Safe in hepatic and renal failure
Hoffman degredation
Fast onset and offset
May cause hypotension and histamine release with
prolonged use
Rx:
– 0.2mg/kg
– Onset of 2 min and lasts 20 min
Who:
– Renal and liver failure patients