“Pediatric Endotracheal Intubation” by Josh Nagler for OPENPediatrics

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , , , , , , /

Pediatric Endotracheal Intubation by Dr. Joshua
Nagler. This instructional video will discuss the
indications and contraindications for tracheal intubation. It will review pertinent airway anatomy, and
the procedural equipment, the steps required to successfully perform tracheal intubation,
including appropriate aftercare, will be demonstrated. Additionally, potential complications and
common pitfalls will be discussed. Use of a standard checklist is recommended
to evaluate each patient for risks associated with tracheal intubation, and generate appropriate
plans to best minimize these risks. Tracheal intubation is an essential skill
utilized to facilitate respiratory support in children with life-threatening conditions,
as well as those who require airway protection, including patients undergoing general anesthesia. This video will not cover bag mask ventilation
or predictors of difficult airways. In addition, the focus here is on the use
of direct laryngoscopy, although there is increasing recognition of potential advantages
to using video laryngoscopy for endotracheal intubation. Indications. Tracheal intubation is indicated for any of
the following– failure of oxygenation or ventilation, inability to maintain or protect
the airway, severe systemic conditions for which stabilization of the airway’s beneficial,
elective anesthesia, or completion of diagnostic or therapeutic procedures which cannot be
performed without a controlled airway. Contraindications. In an emergency, there are no absolute contraindications
to intubation except if the patient has an advanced directive against advanced airway
placement. Relative contraindications to intubation include
an anticipated difficult airway with concerns for difficulty either with bag mask ventilation,
or of successful intubation. In these cases, use of available resources
are encouraged, including consultation with an expert in airway management, activation
of an airway emergency team if this exists in your institution, and preparation for advanced
airway techniques. It is helpful to review a patient’s airway
history if it is available in the medical record, assessing for prior difficulties with
bag mask ventilation or intubation, or if a rescue plan such as a supraglottic airway
placement has been required. Anatomy. Knowledge of the relevant anatomy of the upper
airway and larynx is essential to successful intubation. Key anatomical landmarks to note during intubation
include the epiglottis, vallecula, arytenoids– also known as the posterior cartilages– aryepiglottic
folds, vocal cords, glottic opening. Differentiating the glottic opening from the
esophagus is critical. Equipment. Preparation of equipment is a key step prior
to intubation. Required equipment for tracheal intubation
via direct laryngoscopy includes the following– supplemental oxygen delivery devices, such
as a non-rebreather mask and nasal cannula, bag mask system– either flow-inflating or
self-inflating depending on your department’s practice– laryngoscope handle, laryngoscope
blade of the appropriate size and type for the patient. The laryngoscope should be assembled, and
you should have confirmed that the light source is functioning. Endotracheal tubes that are appropriately
sized for the patient should be available, as well as smaller and larger options to be
used if necessary. A stylet that is strongly recommended for
non-elective intubations. After the stylet is placed, the endotracheal
tube should be placed back into its original packaging so it’s kept clean. CO2-detecting devices, such as a colorimetric
detector, or in-line end-tidal CO2 detector, endotracheal tube securing device, or tape. Suction devices– the team should ensure that
a tonsil-tip suction catheter is attached to wall suction adjusted to 80 to 100 millimeters
of mercury. A flexible suction catheter small enough to
pass into the nares and down the endotracheal tube should also be available. A stethoscope, personal protective equipment,
including gloves and other items as per your department standard, should also be obtained
prior to starting the procedure, and a rescue plan should include alternatives to direct
laryngoscopy, as well as the supraglottic airway. The suggested endotracheal tube size and laryngoscope
blade can be determined by the patient’s age. The predicted correct endotracheal tube size
can be calculated using commonly-accepted formulas, or by using electronic or print
references for resuscitation. Identifying and becoming familiar with a given
approach to endotracheal tube selection in advance can help reduce the cognitive load
during this high-stakes clinical procedure. Ensuring the appropriate personnel are present
for the procedure is critical. The intubation team members may include airway
provider who performs the intubation procedure, team leader– it is ideal to identify a team
leader separate from the airway provider. However, depending upon the situation, this
may not always be feasible. Nursing staff, respiratory therapists. It is important to clarify the responsibilities
of each provider present during the procedure, including who will be handing the endotracheal
tube to the intubator, who will be securing the tube and providing positive pressure ventilation,
and who will be observing the patient’s vital signs during the procedure to alert the intubator
of any significant changes. In cases of a known or anticipated difficult
airway, an otolaryngologist or anesthesiologist with training in pediatric advanced airway
techniques should be consulted whenever available. Prior to the procedure, review local protocols
for calling emergency assistance in the event of an unanticipated difficult tracheal intubation. Procedural steps. The first step, when time allows, is to utilize
a checklist to review intubation risks in the airway management plan. The next step is to choose the appropriate
size and type of endotracheal tube. A stylet should be inserted appropriately
so that it is not protruding from either the end of the tube, or out the Murphy’s eye. Next, the equipment should be rechecked to
ensure that it is all readily available, and in working order. The team should ensure that the patient has
monitoring leads, and a pulse oximeter in place. The blood pressure cuff should be placed on
a different extremity than the pulse oximeter, and set to cycle frequently. Check that the IV is patent and functioning. Waveform capnography can be used to monitor
adequate bag mask ventilation and confirmation of tracheal intubation. The patient should be appropriately positioned
utilizing proper bed height, head position, and a shoulder or head roll, as indicated
by patient age. For an obese patient, one or more pillows
may be required to improve the laryngeal view. This positioning is called ramping. If the procedure is not being performed emergently,
time should be taken to perform a procedural timeout using a checklist. During the timeout, the patient identity should
be verified, the indication for the procedure should be reviewed, and an assessment for
a potential difficult airway should be performed. Consent for intubation or anesthesia can also
be verified. Pre-oxygenation should be performed according
to the area of practice and patient population. The use of a non-rebreather mask or flow-inflating
bag for a minimum of 2 to 3 minutes is commonly used. In patients with inadequate oxygenation or
ventilation, gentle, positive pressure breaths using a bag and mask may be required. The use of apneic oxygenation with continued
delivery of oxygen by nasal cannula may decrease the risk of hypoxemia during laryngoscopic
attempts. There are varied recommendations for flow
rates during apneic oxygenation in pediatric patients– the use of flush rate oxygen delivery,
which is the maximum flow obtained by fully-opening standard oxygen flow meters, is being recommended
for pre-oxygenation in adult patients. The safety of this approach with rates that
may exceed 40 liters per minute has not been established in pediatric patients, and is
not currently recommended. Other pre-procedure physiological optimization
is also recommended. Positive airway pressure may reduce venous
return and preload. In addition, medications used in rapid sequence
intubation can result in sympatholysis, which also affects cardiovascular status. Be careful to ensure that the patient has
had adequate fluid resuscitation, and is hemodynamically supported to the extent feasible prior to
intubation and positive airway pressure. With the exception of crash airways, the use
of medications is recommended to decrease the risk of airway trauma from patient movement
and agitation, and increase the likelihood of a successful intubation. Vagolytics may be used as a pre-medication. In addition, sedatives and the neuromuscular
blocking agent should be given according to the plan discussed in the timeout. Neuromuscular blocking agents may be contraindicated
in patients who are not easy to ventilate with a bag and mask, or in whom difficult
laryngoscopy is suspected. Intubations without the use of neuromuscular
blocking agents are more difficult, and should preferentially be performed by a skilled intubator. Appropriate technique should be applied to
open the mouth prior to inserting the blade. A scissoring technique, or rotation of the
head backward in a neuromuscularly blocked patient can be effective. The blade should be smoothly inserted from
the right corner of the mouth, using the left hand to hold the laryngoscope handle. The tongue should be swept to the left to
optimize the laryngeal view. An alternative approach of inserting the blade
down the midline may also be effective, particularly with intubators with less experience. The laryngoscope handle should be lifted forward
and upward to obtain a view of the glottic opening. Do not rock the handle and blade, or press
against the gums or teeth. Visualized anatomic landmarks can be used
to guide laryngoscope position to visualize the glottic opening. Adjustments can be made to the laryngoscope
insertion depth, or the force being applied to laryngoscope handle to improve visualization. Providers may choose to apply a gentle downward
pressure externally to the larynx to improve visualization of the glottic opening. It is often helpful for the intubator to announce
recognized anatomic landmarks, such as the epiglottis, posterior cartilages, and vocal
cords as they are visualized. Different techniques may be used with different
laryngoscope blade types. The first option is to use a straight, or
Miller, laryngoscope blade placed directly under the tip of the epiglottis, and gently
lift to compress the epiglottis against the base of the tongue to provide visualization
of the glottic opening. The second technique is to advance the tip
of the curved– for example, Macintosh– blade until it lies in the vallecula, just below
the base of the tongue. The entire laryngoscope is then lifted in
the direction of the handle to visualize the glottic opening. Teams must be mindful of the duration of intubation
attempts. The team leader should clearly communicate
with the intubator to stop a given attempt and provide rescue ventilation, ideally before
a patient shows signs of desaturation or clinical deterioration. Prolonged attempts should also be avoided
in patients in whom progressive hypercarbia is of concern– for example, when there’s
a concern for increased intracranial pressure or severe metabolic acidosis. The team leader should be mindful of the speed
of desaturation, particularly in patients who cannot be fully pre-oxygenated prior to
the procedure. When oxygen saturation drops below 93%, the
speed of desaturation accelerates. Intubation can be re-attempted after bag mask
ventilation is performed to stabilize the vital signs. If secretions block the view of the vocal
cords or the glottic opening, then suction should be used to clear the view as needed. Once the glottis and the vocal cords are visualized,
the provider performing the intubation should maintain the laryngoscopic view. The endotracheal tube should be handed to
the intubator by one of the other team members. The tube should be inserted from the right
side of the mouth through the vocal cords using one, smooth motion. Avoid insertion of the endotracheal tube down
the barrel of the blade, as this will block the line of sight. The tube should be advanced into the trachea
to the appropriate depth. The general guideline for the depth insertion
is 3 times the internal diameter of the endotracheal tube when an uncuffed endotracheal tube is
used. The cuffed endotracheal tube should be advanced
until the cuff passes just beyond the vocal cords, and the cuff should be inflated. The laryngoscope is then removed carefully. The provider performing the intubation then
uses his or her fingers to secure the endotracheal tube, commonly by holding it against the hard
palate or upper teeth, while maintaining a part of the hand on the child’s cheek to prevent
movement. If used, the stylet is removed from the endotracheal
tube at this point. The depth of the endotracheal tube at the
upper teeth or gums should be reconfirmed, and to confirm correct endotracheal tube position
within the trachea, the team should use primary and secondary indicators, including equal
breath sounds and chest rise, detection of CO2– either with color change when using
a colorimetric CO2 detector, or a detectable CO2 waveform when using capnography. Once proper endotracheal tube position has
been confirmed, the endotracheal tube should be secured in position using a commercial
endotracheal tube securing device, or tape according to local practice. While the endotracheal tube is being secured,
the provider who performed the intubation should continue to hold the endotracheal tube
in place using their thumb and index finger. Potential complications. Potential complications encountered during
tracheal intubation include hypoxemia, dysrhythmia, including bradycardia, hypotension or hypertension,
bronchospasm, laryngospasm, trauma to the lips and mouth, laryngeal trauma, vocal cord
injury, esophageal intubation, esophageal perforation, bronchial intubation, tracheal
injury, including perforation, emesis with possible aspiration, cardiac arrest. A clearly-defined intubation plan prior to
the procedure should include strategies for optimizing attempts, as well as responding
to unanticipated difficulties. This preparation can be helpful in avoiding
potential complications. During the procedure, providers should take
care during insertion of the intubation equipment, and avoid undue pressure on the fragile tissues
of the airway. The endotracheal tube should not be advanced
until the intubator can clearly visualize the glottis. The endotracheal tube should not be advanced
if the vocal cords are closed. The intubator and team leader should clearly
communicate when to cease an attempt to avoid desaturation, and/or dysrhythmia. After care. Appropriate after care following tracheal
intubation includes confirmation that the endotracheal tube is appropriately secured,
and obtaining a chest X-ray to assess for proper position. An appropriately-placed endotracheal tube
will be below the level of the clavicles, and above the carina. Patients will require continued assisted ventilation,
either with hand bagging or placement on a ventilator depending on the clinical circumstances. Additional medications for analgesia and sedation
need to be considered. Note that some of the medications used for
induction, such as intomidate, may have a shorter duration of effect than the chosen
neuromuscular blocking agent. In this case, additional sedatives should
be administered soon after intubation. Common pitfalls. A number of common issues and pitfalls are
encountered during tracheal intubation. Rocking back on the laryngoscope blade to
avoid this. The provider performing the intubation should
concentrate on lifting, and not rocking the laryngoscope, to obtain a view of the glottic
opening. Inability to visualize the glottic opening–
to assist with laryngoscopic view, the provider should ensure proper positioning of the patient,
adequate suctioning, and proper alignment of the provider’s body and head in relation
to the patient’s larynx. Ensure that the patient’s head is not rotated
or tilted as the laryngoscope is maneuvered into position. The chest, to the intubator, should be aligned
with the patient’s head. The goal is to create a direct line of sight
between the intubator’s eyes and the patient’s glottis. Inadequate glottic visualization may also
occur because the laryngoscope has been inserted too deep. This is particularly true in young infants. Slowly withdrawing the blade under direct
visualization can be used to identify key anatomic structures. External laryngeal manipulation can also improve
partial visualization. Gentle pressure on the larynx can move anatomic
structures into better view. Right main stem intubation– advancing the
endotracheal tube too far into the trachea will result in a bronchial intubation. Consideration of the appropriate insertion
depth during the intubation plan can be helpful. Tubes may be marked or taped ahead of time
as a visual cue. During the procedure, the depth of insertion
should be guided by the lines on the endotracheal tube, or until the cuff is visualized to just
past the vocal cords. Multiple attempts– physiological and pharmacological
optimization, as well as appropriate positioning prior to the procedure, can help minimize
repeated attempts. In addition, the intubation skill level should
be matched to the anticipated level of difficulty of the procedure. Multiple attempts by a single provider should
be avoided. More experienced providers should make subsequent
attempts. Calling for help early may be needed to bring
appropriate personnel resources. Equipment issues– choosing the correct size
laryngoscope blade and endotracheal tube is important for intubation success. Using a systematic approach to selecting appropriate
equipment can be helpful. Formulas, length-based systems, or electronic
or printed resources can be used to reduce the cognitive load during this critical procedure. Cuffed endotracheal tubes offer flexibility
to adjust the fit of the tube as needed. Current guidelines suggest cuffed and uncuffed
endotracheal tubes are equally safe, and may offer advantages in select patients. We recommend routine use of cuffed endotracheal
tubes, provided attention is paid to correct endotracheal tube size, and cuff inflation
pressure. End-tidal CO2 detection is the most accurate
means of confirming endotracheal tube placement. Failure to detect end-tidal CO2 may be due
to an esophageal intubation, cardiac arrest with insufficient pulmonary blood flow, or
equipment malfunction. Note that CO2 may be detected initially, even
if the endotracheal tube is misplaced in the esophagus. However, in this case, CO2 will no longer
be detectable after a few breaths. This concludes this instructional video on
pediatric orotracheal intubation. In this video, we reviewed the indications
and contraindications for orotracheal intubation. We reviewed pertinent airway anatomy, detailed
the equipment used, and demonstrated the steps required to successfully perform orotracheal
intubation. Additionally, we examined appropriate aftercare,
potential complications, and reviewed common pitfalls and strategies to address them. This video was developed in cooperation with
the International Network for Simulation-based Pediatric Innovation, Research, & Education,
or INSPIRE. Please help us improve the content by providing
us with some feedback.

3 thoughts on ““Pediatric Endotracheal Intubation” by Josh Nagler for OPENPediatrics

  1. Thank you to BCH that does such a great work on pediatric education through these videos.  I am a educator full time now and no longer at the bedside.  Your videos help keep me current and relevant.

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