Assessment
A comprehensive airway evaluation is a critical component of airway management in children and infants.

History

  • Past medical history and birth history
  • Airway-related comorbidities
  • Prior airway management/ complications during anesthesia
  • Surgical procedures involving the airway.

Physical Exam

A focused airway exam:

  • Evaluation of the mandible, maxilla, and tongue size
  • Loose or missing teeth
  • Gross anatomic abnormalities

 

  • Thyromental Distance:
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thyromental distance
Appropriate thyromental distance varies with age and height. An alternate estimate is to evaluate if the distance between the mentum and the neck/mandible junction (near the hyoid bone) is equal to or greater than the width of 3 patient fingers.

Assessment of Airway Before Intubation

Remote video URL

Alexander Connelly, Young May Cha. Pediatric Airway Evaluation [Internet]. 2024. Available from: https://www.openanesthesia.org/keywords/pediatric-airway-evaluation/ 

Assessing the Pediatric Airway Prior to Intubation by T. Miller [Internet]. Available from: https://youtu.be/UIvtoi2UZ-4?si=NZWLM9BGmEZCZFqn. 

Equipment

Personal Protective Equipment (PPE)

  • Mask
  • Eye Protection
  • Gown
  • Gloves

Monitoring Equipment

  • Pulse oximetry
  • Non-invasive blood pressure monitoring (either automated or manual)
  • Cardiac monitor
  • End Tidal CO2 (ETCO2) or if unavailable use a colorimetric device

Airway Equipment

Airway Equipment Size Guide

  • Endotracheal Tube (ETT)
A cuffed ETT is recommended for all children 

Estimated endotracheal tube size

  • CUFFED ETT = age / 4 + 3.5
    UNCUFFED ETT = age / 4 + 4

 

  • This formula yields the inside diameter of the tube in mm
  • Always have an ETT half size smaller for back up

 

  • Suction Device
    • Rigid oral suction system (Yankaeur) with regulator set to maximum suction level
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yankaeur device
  • Pediatric Laryngoscope
    • The video laryngoscopes are preferred if there is a suitable blade size but may not be available in many centres
    • The Pediatric Advanced Life Support (PALS) checklist describes recommended laryngoscope sizes and blade types for patient age.
      • For neonates and infants, a Miller/Robertshaw laryngoscope blade is recommended.
      • For older children, the Macintosh blade is recommended.
Image
laryngoscope blade
  • Stylet
    Semi-rigid stylet (for endotracheal tube), lubricated with any water based lubricating jelly.
    • Satin-slip stylet by Mallinckrodt is recommended if available.
    • Stylet should be shaped to reflect a hockey stick prior to insertion.
Image
Sty;et
  • 5 mL Syringe
    To inflate cuff with 1 to 2 mL air after successful intubation

     

  • Peripheral Intravenous (IV) Access
    Ensure functioning IV access available

BCCH Pediatric Intensive Care Unit – Medical Director. INTUBATION IN PEDIATRIC PATIENTS [Internet]. 2022. Available from: https://shop.healthcarebc.ca/phsa/BCWH_2/BC%20Children%27s%20Hospital/C-05-07-62873.pdf 

Checklist

See Appendix A

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intubation checklist

BCCH PICU – Medical Director, Quality & Safety Leader, Respiratory Therapy Educator. Endotracheal Intubation [Internet]. BC Children’s and BC Women’s Hospitals; 2022. Available from: https://shop.healthcarebc.ca/phsa/BCWH_2/BC%20Children%27s%20Hospital/C-05-12-62073.pdf 

Preparation
  • Positioning
Image
intubation positioning
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intubation positioning
  • Pre-Oxygenation
    Prior to every intubation attempt, maintain with oxygen via nasal prongs ( <1 yr = 5LPM, 1-7 yr = 10LPM, > 7 yr = 15 LPM), in addition to 100% oxygen via bag-valve-mask (tight anatomical seal; see Figure below)
Image
pre-oxigen intubation

This should be maintained while preparing equipment and medications
If the face mask seal is impaired by the nasal prongs, remove the nasal prongs and optimize bag mask ventilation/oxygenation
 

Image
Single hand technique for bag valve mask

 

Preventing Hypotension

Hypovolemia, sedative medications and positive pressure ventilation may result in hypotension during the intubation procedure.

  • Fluid bolus ( isotonic crystalloid solution fluid bolus 10-20mL/kg IV)
  • Inotropes/vasopressor
  • Spritzer Epinephrine - 1 mcg/kg epinephrine IV bolus as required.
Image
Epi, Spritzer Epinephrine

Karla A. Atlas of Pediatric Intubation Technique [Internet]. Pediatric Anesthesia. Digital Handbook. 2023. Available from: https://www.maskinduction.com/atlas-of-pediatric-intubation-technique.html 

BCCH Pediatric Intensive Care Unit – Medical Director. INTUBATION IN PEDIATRIC PATIENTS [Internet]. 2022. Available from: https://shop.healthcarebc.ca/phsa/BCWH_2/BC%20Children%27s%20Hospital/C-05-07-62873.pdf 

BC Children’s Hospital. How to reconstitute an Epi spritzer 10mcg/ml. 2024. 

Medication

If the weight is not immediately known or easily estimated, use age on weight based drug sheets on this site or a Broselow tape can be used for the purpose of drug dosages (as well as ET tube sizing).  

  • Sedation, Analgesia, & Paralytics: Consider having multiple doses at the bedside for the procedure.

 

Ketamine 1mg/kg

Rocuronium 1mg/kg

Fentanyl 1 mcg/kg (adjunct)

If the child is hypertensive following intubation, a repeat dose of ketamine or fentanyl can be administered.