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Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1).3
Routine use of cricoid pressure is not recommended during endotracheal (ET) intubation of pediatric patients. If cricoid pressure is used, discontinue it if it interferes with ventilation or intubation.12
Ensure that cervical spinal motion restriction is in place and neck flexion is avoided during intubation if the patient has or may have a cervical spine injury.
Limit intubation attempts to 30 seconds.10
Avoid hyperoxygenation, hyperinflation, and hyperventilation.
An ET tube is placed into the trachea via the oral or nasal route to maintain airway patency, facilitate the clearance of secretions, provide positive pressure ventilation, and deliver emergency medications.
Indications for ET intubation include:4,11
Pediatric patients have certain characteristics that affect intubation.
In pediatric patients, a cuffed ET tube is preferred over an uncuffed ET tube.12 As long as an oral cuffed tube is closely monitored, it does not have a greater rate of complications than an uncuffed tube.1 Cuffed tubes are typically used for pediatric patients with decreased lung compliance or for patients with a large air leak when an uncuffed tube is used. Cuffed tubes in young children may contribute to subglottic damage if the pressure exerted by the tube or cuff exceeds mucosal capillary pressure. Current recommendations for the placement of a cuffed ET tube in a child include monitoring and limiting cuff pressure and ensuring that an audible air leak is present at a pressure of 25 cm H2O or less with the patient’s head in the midline position.8 If the cuffed ET tube is inserted nasally, the chances of complications are significantly higher.2 The ET tube should be kept at least 0.5 cm above the carina to avoid complications.2
An appropriate-size face mask provides a tight seal and extends from the bridge of the nose to the cleft of the chin, encompassing the mouth and nose but avoiding the eyes (Figure 2).
Several methods can be used to determine the ET tube size (internal diameter). For patients younger than 1 year old, these sizes are recommended:10
ET tube size based on the patient’s body length is more reliable. Length-based resuscitation tapes can be used to determine proper tube size. For patients older than 2 years of age, these formulas may be used:10,11
Both straight and curved laryngoscope blades are available for intubation.10,11
Two types of resuscitation bags are commonly used for manual ventilation: a self-inflating manual resuscitator and a flow-inflating manual resuscitator, sometimes called an anesthesia bag. Although both resuscitators serve the same purpose, they require different techniques and skill levels.
Head position affects ET tube position. Neck flexion results in the tip of the tube moving closer to the carina or inadvertent endobronchial displacement, whereas neck extension draws the tube toward the glottis or results in displacement into the pharynx and possibly extubation.11
The possible complications of intubation include sinusitis, vocal cord injury, laryngeal injury and stenosis, tracheal injury, and pulmonary infection.11
The mnemonic DOPE indicates the possible causes of deterioration in an intubated child’s condition.
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For procedures that must be performed emergently: Comply with Universal Protocol only if it does not delay the procedure.
Rationale: Drug-facilitated intubation, formerly rapid sequence intubation, is a systematic way to intubate a patient quickly, safely, and with minimal anxiety or pain. Specific medications vary by organization and practitioner. Major steps include preoxygenation, sedation, pain management and prevention, induction, neuromuscular blockade, intubation, and placement verification.
Rationale: Oropharyngeal suctioning may be needed.
Rationale: The sequencing and timing of drug administration depends on the situation and the patient.
If a neuromuscular blocking agent is to be used, it should always be given after the sedative or induction agent has been administered.
When atropine is used as a premedication for emergency intubation, minimal dosing requirements no longer apply.
Rationale: This positioning enables observation of the vocal cords.
If the situation is urgent or emergent, perform this step simultaneously with other steps.
Rationale: The infant’s or toddler’s proportionately large occiput raises the head and causes neck flexion, misaligning the axes.
Perform neck flexion and extension only if neck or head trauma is not suspected. Ensure that cervical motion restriction is in place if the patient has or may have a cervical spine injury.
Rationale: Preoxygenation helps prevent hypoxemia. Gentle breaths reduce the incidence of air entering the stomach, leading to gastric distention.
Rationale: Asymmetric movement may indicate right mainstem intubation, esophageal intubation, or a pneumothorax.
Rationale: Listening over the axillae limits hearing referred breath sounds from the opposite lung.
Rationale: Unilateral or unequal breath sounds indicate that the ET tube is inserted too far and is in the right or left mainstem bronchus.
Rationale: No breath sounds, air entering the stomach, and no color change on the ET
2 detector indicate that the ET tube is in the esophagus.
Attempt to maintain an air leak with cuff pressure less than 25 cm H2O to reduce the risk of tracheal damage.8 If no air leak is present, determine whether the ET tube is too large, the ET tube cuff is excessively inflated, or laryngospasm is occurring.
Rationale: The best method of securing the ET tube ensures maximum airway security with minimal risk of unwanted movement and unplanned extubation as well as ease of use, facial skin integrity, and infection control.
Rationale: Monitoring breath sounds allows detection of ET tube migration or dislodgment.
Reportable conditions: Absent, decreased, or unequal breath sounds
Rationale: Recording the position of the ET tube helps identify ET tube migration or dislodgment.
Reportable condition: ET tube movement from original position
Reportable conditions: Unplanned extubation, poor tape integrity
Rationale: The cuff should be inflated to the minimal pressure necessary to seal an air leak and allow effective ventilation. High cuff pressures may precipitate tracheal damage.
Reportable conditions: Inability to pass a suction catheter through the ET tube, significant changes in the amount or character of secretions
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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