Skip to content

Intubation

SHARE VIA:

Share on facebook
Share on twitter
Share on linkedin
Share on whatsapp

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.

About the authors

KEEP READING

High flow therapy – when and how?

Chest compressions in traumatic cardiac arrest

Searching for sepsis

The missing link? Children and transmission of SARS-CoV-2

Don’t Forget the Brain Busters – Round 2

An evidence summary of Paediatric COVID-19 literature

Urticaria

The fidget spinner craze – the good, the bad and the ugly

Parenteral Nutrition

Leave a Reply

Your email address will not be published.

DFTB WORLD

EXPLORE BY TOPIC

We use cookies to give you the best online experience and enable us to deliver the DFTB content you want to see. For more information, read our full privacy policy here.
[cmplz-manage-consent]