Paediatrics: Endotracheal intubation

Endotracheal intubation

Indications 

This procedure is used as part of advanced resuscitation and care.

Equipment

•   Appropriately-sized laryngoscope: neonatal laryngoscopes are straight; blade size starts at 0 (7.5cm long) for use in preterm infants. Use size 1 (10cm) in term infants. In older children use curved blade laryngoscopes (Macintosh).

•   ETT size: 2–2.5mm (internal diameter) in infant <1000g; 3mm when 1000–3000g; 3.5mm when >3000g. The appropriate size then increases as child size increases up to male adult size of 8–9mm. Cole (shouldered) ETTs are suitable for oral intubation in newborns. Straight (non-shouldered) tubes can be used for oral or nasal intubation.

•   Appropriately-sized introducer if required.

•   Lubricating jelly if attempting nasal intubation.

•   Magill forceps if attempting nasal intubation.

•   Suction catheter and tubing connected to suction source.

•   Appropriate ETT connection adaptors, tubing, and O₂ source.

•   Fixation device and tape.

Procedure

•   Oral intubation is preferred during short-term intubation or during resuscitation. Nasal intubation has advantages if ventilation is prolonged.

•   Check laryngoscope light, O₂ supply, and suction.

•   Connect child to pulse oximeter and cardiac monitor.

•   Sedation or anaesthesia should be given prior to elective intubation.

•   Pre-oxygenate the child by hyperventilation with 85% O₂ for 15–30s prior to elective intubation.

•   Place the child in the supine position with the head in the neutral position and the neck slightly extended.

•   Stand immediately behind the child’s head.

•   If nasal intubation is being performed, a prelubricated ETT should be passed into one nostril as far as the nasopharynx prior to insertion of laryngoscope. If the ETT will not pass easily, do not try force, as this may lead to penetration of the cribriform plate.

•   Open the mouth and use suction to clear airway secretions.

•   Holding the laryngoscope in the left hand, initially insert the blade to the right side of the mouth and advance to the base of the tongue.

•   Once inserted move the laryngoscope blade into the centre of the mouth, thereby pushing the tongue to the left.

•   Advance the blade further until epiglottis is seen and then insert blade tip into the valleculla (space between base of tongue and epiglottis).

•   Vertically lift up the whole blade, thereby exposing the vocal cords (see Fig. 7.3). Apply cricoid pressure with the little finger of the left hand to see the vocal cords. Perform suction if needed.

• If the vocal cords cannot be seen after 30s do not try to attempt blind intubation. Abandon the attempt, maintain patent airway, and perform mask ventilation, before trying again.

• Once the vocal cords are seen, insert the ETT between the vocal cords. If difficult, or performing nasal intubation, use the Magill forceps with the right hand to advance the ETT tip.

• If using a straight tube, the ETT should be advanced until the thick black line at the tip is level with the vocal cords. If using a Cole ETT, advance it until the shoulder just reaches the vocal cords.

• If using a cuffed tube advance until the cuff is just below the vocal cords and no further. Then inflate the cuff with air using a syringe.

• Once intubation is successful, connect tubing and ventilate.

• Visually check chest movement and auscultate over each lung to ensure appropriate and equal bilateral air entry.

• If this procedure is successful, SpO₂ and heart rate should improve.

• Fix ETT in place appropriately following local institutional guidelines.

• Perform a CXR to confirm position of ETT, which should ideally be 1–2cm above the carina, depending on the childs’ size.

• Causes of failure to intubate include: poor visualization of vocal cords due to over extension of neck or advancement of laryngoscope too far into the oesophagus; spasm of vocal cords (wait, as almost certainly vocal cords will open eventually—do not attempt to force ETT through as this may cause damage); anatomical abnormalities, e.g. laryngeal atresia; vocal cord oedema.

• Conditions that may give an impression of failed intubation (little or no chest movement on ventilation after intubation) include: thoracic pathology (e.g. tension pneumothorax, diaphragmatic hernia); intubation of the right main bronchus (detected by unequal air entry); and particulate obstruction of airway or ETT.