Overview
Pediatric Intubation is a critical airway management procedure used to establish a secure airway in children who cannot maintain adequate oxygenation or ventilation. This procedure requires specific techniques adapted for pediatric anatomy and physiology.
Pediatric intubation is essential for managing respiratory failure, airway obstruction, and neurological emergencies in children. Proper technique is crucial as pediatric airways have unique anatomical considerations. This procedure can be life-saving in emergency situations.
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Indications
Inability to maintain adequate oxygenation or ventilation
Upper airway obstruction not responsive to other measures
Decreased level of consciousness with airway compromise
As part of advanced life support
Trauma with airway compromise or respiratory failure
General anesthesia requiring endotracheal tube
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes ensuring all intubation equipment is available and properly sized, checking oxygen supply and monitoring equipment, assembling the intubation team, and preparing for potential complications. All team members should understand their roles.Step-by-Step Procedure
Step 1: Preparation and Pre-oxygenation
Assemble team and equipment. Pre-oxygenate with 100% oxygen for 3-5 minutes. Position patient in sniffing position. Administer premedication if indicated (atropine, lidocaine).
⚠️ Common Mistakes to Avoid:
- Inadequate pre-oxygenation
- Poor patient positioning
- Missing premedication when indicated
💡 Pro Tip:
Pre-oxygenation is crucial - aim for end-tidal oxygen >90% before intubation.
Step 2: Induction and Paralysis
Administer induction agent (ketamine, etomidate, propofol). Follow with neuromuscular blocking agent (succinylcholine, rocuronium). Ensure adequate sedation and paralysis.
⚠️ Common Mistakes to Avoid:
- Inadequate sedation causing patient movement
- Insufficient paralysis
- Wrong medication doses
💡 Pro Tip:
Use rapid sequence intubation (RSI) for emergency intubations.
Step 3: Laryngoscopy Technique
Insert laryngoscope blade along right side of mouth. Sweep tongue to left. Advance blade to vallecula. Lift anteriorly to expose vocal cords. Avoid levering on teeth.
⚠️ Common Mistakes to Avoid:
- Levering on teeth causing dental trauma
- Poor blade positioning
- Inadequate exposure of vocal cords
💡 Pro Tip:
Use gentle, steady pressure to lift the epiglottis without levering on teeth.
Step 4: Tube Placement
Insert endotracheal tube through vocal cords. Advance to appropriate depth (age/2 + 12 cm). Remove stylet and inflate cuff if used. Confirm placement.
⚠️ Common Mistakes to Avoid:
- Wrong tube size selection
- Incorrect depth placement
- Failure to confirm placement
💡 Pro Tip:
Use age-based formulas for tube size: (age/4) + 4 for uncuffed tubes.
Step 5: Confirmation of Placement
Confirm placement with multiple methods: chest rise, breath sounds, capnography, chest X-ray. Secure tube with tape or commercial device. Document depth.
⚠️ Common Mistakes to Avoid:
- Relying on single confirmation method
- Poor tube securing
- Inadequate documentation
💡 Pro Tip:
Always use multiple methods to confirm tube placement - capnography is gold standard.
Step 6: Post-intubation Management
Connect to ventilator or bag. Monitor vital signs, oxygen saturation, and end-tidal CO2. Provide appropriate sedation and analgesia. Order chest X-ray.
⚠️ Common Mistakes to Avoid:
- Inadequate monitoring
- Poor sedation management
- Missing chest X-ray
💡 Pro Tip:
Maintain appropriate sedation to prevent accidental extubation.
Step 7: Documentation and Handoff
Document procedure details, medications given, tube size and depth, and any complications. Provide clear handoff to receiving team. Monitor for complications.
⚠️ Common Mistakes to Avoid:
- Incomplete documentation
- Poor handoff communication
- Inadequate monitoring
💡 Pro Tip:
Document everything - this is a high-risk procedure requiring detailed records.
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Post-procedure Care
Post-intubation care involves securing the tube, confirming placement, monitoring vital signs and oxygen saturation, and providing appropriate sedation and analgesia. Continuous monitoring and documentation are essential.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Esophageal intubation | 5-10% | No chest rise, no breath sounds, no capnography | Immediate extubation, re-intubate | Multiple confirmation methods, capnography |
| Dental trauma | 2-5% | Broken or loose teeth, bleeding | Dental consultation, document findings | Gentle technique, avoid levering |
| Right mainstem intubation | 10-15% | Asymmetric breath sounds, decreased left lung | Withdraw tube to appropriate depth | Proper depth calculation, confirmation |
| Laryngospasm | 1-3% | Inability to ventilate, stridor | Positive pressure, consider succinylcholine | Adequate paralysis, gentle technique |
| Hypoxemia | 10-20% | Decreased oxygen saturation | Optimize ventilation, check tube position | Adequate pre-oxygenation, rapid intubation |
Clinical Pearls
Pre-oxygenation is crucial - aim for end-tidal oxygen >90% before intubation.
Use rapid sequence intubation (RSI) for emergency intubations.
Use age-based formulas for tube size: (age/4) + 4 for uncuffed tubes.
Always use multiple methods to confirm tube placement - capnography is gold standard.
Document everything - this is a high-risk procedure requiring detailed records.
Maintain appropriate sedation to prevent accidental extubation.
Use gentle, steady pressure to lift the epiglottis without levering on teeth.