Intubation

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Indication:

  • to secure the airway: severe airway obstruction/inadequate protective reflexes (coma or prolonged seizures)
  • to facilitate ventilation: hypoxaemic and/or hypercarbic respiratory failure

Intubation should NOT be attempted by the inexperienced if more skilled personnel are available. Two doctors always present if possible!


Assessment:

  • how urgent is the intubation?
  • anatomical abnormality, which would suggest difficult intubation?
  • any evidence of airway obstruction?
  • cardiovascular status – any hypovolaemia/hypotension?
  • is the patient fasted?

 Preparation equipment:

  • intubation drugs
  • volume replacement (10ml/kg NaCl 0.9%)
  • ETT (size = age/4 + 4 – for uncuffed ETT for cuffed ETT size = age/4 + 3.5), one size above and one size below calculated ETT
  • styllete, gum elastic bougie
  • laryngoscope with blade (check light bulb and battery)
  • Magill’s forceps
  • face mask
  • Guedel and nasopharyngeal airways
  • self inflating bag and anaesthetic circuit
  • suction equipment: Yankauer’s sucker and suction catheters
  • connector, cuff inflating syringe, tape
  • CO2 detector

Procedure:

  • monitor cardiovascular and respiratory status (ECG, SpO2, BP non-invasive/invasive)
  • explain to patient/parents
  • empty stomach if nasogastic tube is in situ
  • position patient: neutral position in neonates, young children – sniffing position in older children, adolescents
  • preoxygenation for minimum two minutes
  • consider atropine 20 mcg/kg IV
  • give analgesic agent
  • give sedative agent
  • apply gentle pressure to the cricoid
  • check for bag and mask ventilation possible with appropriate visual inflation/deflation and chest wall movement
  • give paralysis agent
  • continue bag and mask ventilation, while continuing to apply gentle cricoid pressure, except in circumstances where bag and mask ventilation is contraindicated (see rapid sequence induction)
  • intubate orally, release cricoid pressure
  • check ETT position: chest wall rise, auscultation and CO2 detector
  • once patient stabilised and appropriate ventilation, consider to change to a nasal ETT
  • once ETT position confirmed, tape ETT
  • insert nasogastric tube, empty stomach
  • CXR to confirm position of ETT and nasogastic tube
  • consider ongoing analgesia and sedation
  • document event

Intubation drugs:

see analgesia and sedation in PICU

Analgesia Sedation Paralysis
cardiovascular stable, no airway obstruction > 1 year

Fentanyl1 – 2mcg/kg

or

Morphine

100mcg/kg

Propofol1 – 2.5mg/kg Vecuronium 0.1mg/kg
cardiovascular stable, with airway obstruction > 1 year

Fentanyl1mcg/kg

or

Morphine

100mcg/kg

Ketamine1 – 2mg/kg Vecuronium 0.1mg/kg
cardiovascular stable, no airway obstruction < 1year

Fentanyl1 – 2mcg/kg

or

Morphine

100mcg/kg

Midazolam50 -100mcg/kg Vecuronium 0.1mg/kg
cardiovascular stable, with airway obstruction < 1 year Always seek senior assistance!Consider induction with volatile anaesthetic!
cardiovascular unstable, any age

Fentanyl1 – 2mcg/kg

or

Morphine

100mcg/kg

Vecuronium0.1mg/kg
rapid sequence induction

Fentanyl1 – 2mcg/kg

or

Morphine

100mcg/kg

Midazolam50 -100mcg/kg Rocuronium1mg/kg
patients with raised ICP

Fentanyl1 – 2mcg/kg

or

Morphine

100mcg/kg

Thiopentone2 – 7mg/kg Rocuronium1mg/kg
anticipated difficult airway Always seek senior assistance!Consider induction with volatile anaesthetic!

 


Unexpected difficult intubation:

  • call for help!
  • restart bag and mask ventilation with gentle cricoid pressure
  • optimise patient position
  • consider bougie or stylete
  • consider different laryngoscope blade

Cannot ventilate – cannot intubate:

  • call for help!
  • consider reposition of head
  • jaw thrust
  • insert Guedel/nasopharyngeal airway
  • use both hands to hold mask
  • release cricoid pressure
  • consider laryngeal mask (LMA)

    All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or AndroidA list of contributors can be seen here.

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