BEFORE Intubation

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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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

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)

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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• 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.

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• 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.

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• 5 mL Syringe
  To inflate cuff with 1 to 2 mL air after successful intubation

   

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

See Appendix A

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• Positioning

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• 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)

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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
 

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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.

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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.