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 Android. A list of contributors can be seen here.
