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.undefined#ref7">7
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.
Avoid hyperoxygenation, hyperinflation, and hyperventilation.
OVERVIEW
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.
Upper airway obstruction (anatomic or functional) or potential for obstruction (e.g., facial trauma, inhalation injuries)
Shock
Hypoxemia despite supplemental oxygen in the absence of congenital heart disease
Inadequate ventilation
Need for airway control for deep sedation or transport
Emergency medication administration
Altered mental status
Increased intracranial pressure
Pediatric patients have certain characteristics that affect intubation.
A child’s airway is smaller in diameter and shorter than an adult’s airway (Figure 1).
During inspiration, the infant’s intercostal muscles contract, and a downward movement of the diaphragm results in negative intrathoracic pressure and air movement into the lungs. Because the infant’s chest wall is compliant and flexible, it characteristically collapses inward.
In adolescents and adults, the larynx is a cylinder with its narrowest portion at the glottic inlet at the level of the vocal cords.
The child’s funnel-shaped larynx is higher and more cephalad and lies below the vocal cords. The vocal cords are cartilaginous and are attached lower and more anteriorly.
The cricoid cartilage is the only landmark in prepubertal patients because the thyroid does not assume its adult configuration until puberty. The cricoid cartilage is the narrowest portion of the upper airway in small children.
The infant’s epiglottis is floppy, long, and narrow and projects more posteriorly than that of an older child. The subglottic airway is smaller and more compliant, and the cartilage is less developed than in the adult.
Infants, toddlers, and school-age children have a large occiput, increasing the risk of airway obstruction when lying supine due to hyperflexion of the neck.11
Peripheral airway resistance is disproportionately higher in the pediatric patient.
The number of alveoli increases until age 8 years, and thereafter, the alveoli increase in size and complexity.5
In pediatric patients, a cuffed ET tube is preferred over an uncuffed ET tube.7 As long as an oral cuffed tube is closely monitored, it does not have a greater rate of complications than an uncuffed tube.3 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 20 cm H2O or less with the patient’s head in the midline position.13
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). General guidelines based on age can be used (Table 1).4 For patients older than 1 year, formulas may be used (Table 2).12 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.
Both straight and curved laryngoscope blades are available for intubation (Table 3).7
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.10
The possible complications of intubation include sinusitis, vocal cord injury, laryngeal injury and stenosis, tracheal injury, and pulmonary infection.10
The mnemonic DOPE indicates the possible causes of deterioration in an intubated child’s condition.1
Displacement of the tube
Obstruction of the tube
Pneumothorax
Equipment failure
SUPPLIES
See Supplies tab at the top of the page.
EDUCATION
Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain the intubation procedure, including its rationale and risks. Risks include injuries to the pharynx and larynx and vocal cord paralysis.
Explain that medications, including sedatives and analgesics, will be used to minimize the patient’s pain and anxiety during the procedure.
Provide guidance regarding the expected duration of intubation.
Discuss the appropriate expected outcomes of intubation.
Explain the sensory implications of an airway in the nose or mouth. Explain that the patient will be unable to speak.
Explain that to ensure the patient’s safety and prevent accidental tube dislodgment, immobilization in conjunction with the use of sedatives may be needed. Explain that these interventions will be used only when necessary.
Review the adjunct monitoring and support that will occur after intubation, such as cardiopulmonary monitoring, pulse oximetry monitoring, blood gas sampling, ventilator assistance, and chest radiographs.
Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
Assessment
Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Introduce yourself to the patient and family.
Verify the correct patient using two identifiers.
Assess the patient’s developmental level and ability to interact.
Verify the patient’s daily weight in kilograms. Do not use stated, estimated, or historical weight.8
Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
Assess the patient’s level of anxiety, consciousness, and respiratory compromise.
Review the patient’s history for drug allergies.
Determine the patient’s last enteral intake of food or liquids.
Assess the patient for a traumatic brain injury and cervical spine injury.
Assess the patient for a history of trauma.
Assess the patient for signs and symptoms of inadequate oxygenation and ventilation.
Assess the patient for hypovolemia, respiratory failure, and hemodynamic instability.
Determine if the patient has IV access.
Determine the family’s desire to be present during the procedure.
Determine the patient’s desire for the family to be present during the procedure.
Preparation
Comply with Universal Protocol, if time permits.
Use a standardized list to verify that all required items, including informed consent, are available.
Mark the procedure site when required.
For procedures that must be performed emergently: Comply with Universal Protocol only if it does not delay the procedure.
Ensure that all equipment and supplies have been collected and are working properly.
Oxygen, including delivery system (e.g., bag-mask devices, tubing, masks)
Suction source and suction catheters
ET tube supplies
Appropriate-size ET tubes; one size smaller and one size larger
Medications, which may include anxiolytics, analgesic, and neuromuscular blockers per the practitioner’s order
Calculate and prepare doses of the prescribed medications.
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.6
Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.9
PROCEDURE
Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure to the patient and family and ensure that they agree to treatment.
Monitor the patient’s vital signs and indicators of adequate oxygenation and ventilation before, during, and after the procedure.
Ensure that the suction apparatus is functional. Connect the suction tubing to a rigid suction-tip catheter. Have pliable suction catheters available.
Rationale: Oropharyngeal suctioning may be needed.
If time permits, comply with Universal Protocol: Perform a time-out to verify the correct patient, correct site, and correct procedure.
Administer intubation medications as prescribed.
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.2
Wait for the onset of action of the medications. Ensure adequate sedation before any intubation attempts.
Assist with positioning the patient’s head. Position the patient supine so the oropharyngeal and laryngeal axes are aligned.
Rationale: This positioning enables observation of the vocal cords.
If the situation is urgent or emergent, perform this step simultaneously with other steps.
Infant and toddler: Place a roll or pad under the shoulders and upper torso to place the patient in a sniffing position. This places the head in neutral position on a flat surface (Figure 3A).
Rationale: The infant’s or toddler’s proportionately large occiput raises the head and causes neck flexion, misaligning the axes.
Preschool-age and older child: Use the head-tilt chin-lift to open the airway (Figure 3B).
Patient with a suspected or confirmed spinal cord injury: Maintain the head in a neutral position with inline cervical spinal motion restriction (Figure 3C).
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.
Open the airway and preoxygenate with high-flow oxygen via a nonrebreather mask for at least 3 minutes.7 If peripheral oxygen saturation (SpO2) cannot be maintained, administer gentle breaths, using a bag-mask device attached to an oxygen source. Administer a sufficient volume of oxygen to ensure chest rise.
Rationale: Preoxygenation helps prevent hypoxemia. Gentle breaths reduce the incidence of air entering the stomach, leading to gastric distention.
While the intubator holds the tube securely in place, provide positive pressure ventilation and confirm ET tube placement.
Primary methods of verification include:
Observing the chest for symmetric movement with each breath
Rationale: Asymmetric movement may indicate right mainstem intubation, esophageal intubation, or a pneumothorax.
Auscultating bilateral breath sounds near both axillae with each breath
Rationale: Listening over the axillae limits hearing referred breath sounds from the opposite lung.
Secondary methods of ET tube placement verification, which can be used after a few seconds of manual ventilation, include:
Checking for an increase in heart rate and SpO2 if bradycardia and hypoxia were present before the procedure
Observing the ETCO2 detector for a change in color or, if using capnography, a reading within normal limits
If auscultation reveals unilateral or unequal breath sounds, auscultate for improved breath sounds while the intubator withdraws the ET tube slightly.
Rationale: Unilateral or unequal breath sounds indicate that the ET tube is inserted too far and is in the right or left mainstem bronchus.
If auscultation detects no breath sounds or detects air entering the stomach and no color change appears on the ETCO2 detector, withdraw the ET tube and prepare for a new insertion attempt after the patient is stabilized with bag-mask ventilation, if necessary.
Rationale: No breath sounds, air entering the stomach, and no color change on the ETCO2 detector indicate that the ET tube is in the esophagus.
Assess the ET tube for an air leak to verify the appropriate ET tube size.
With the patient’s head in a neutral position, place a stethoscope diaphragm on the anterior neck over the trachea.
With a manometer connected to a ventilation bag, administer positive pressure ventilation while auscultating for an air leak.
Attempt to maintain an air leak with a cuff pressure of 20 cm H2O or less to reduce the risk of tracheal damage.13 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.
Clean the patient’s face and secure the ET tube while the patient’s head is in a neutral position per the organization’s practice.
Obtain a chest radiograph for definitive confirmation of correct ET tube placement.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.
MONITORING AND CARE
Monitor breath sounds immediately after intubation, with each assessment, and with changes in status.
Rationale: Monitoring breath sounds allows detection of ET tube migration or dislodgment.
Reportable conditions: Absent, decreased, or unequal breath sounds
Record the position of the ET tube at the teeth, gums, or nose using the centimeter markings on the tube as a reference.
Rationale: Recording the position of the ET tube helps identify ET tube migration or dislodgment.
Reportable condition: ET tube movement from original position
With every patient interaction, assess ET tube stability and the integrity of the tape or securement device.
If using a cuffed ET tube, monitor cuff pressure per the organization’s practice and maintain the cuff pressure at 20 cm H2O or less.13
Rationale: The cuff should be inflated to the minimal pressure necessary to seal an air leak and allow effective ventilation. High cuff pressure may precipitate tracheal damage.
Preoxygenate the patient if indicated and suction the ET tube as needed.
Reportable conditions: Inability to pass a suction catheter through the ET tube, significant changes in the amount or character of secretions
Assess, treat, and reassess pain.
EXPECTED OUTCOMES
Proper placement of appropriate-size ET tube
Properly secured ET tube
Improved oxygenation and ventilation
Decreased work of breathing
Improved secretion clearance
Hemodynamic stability
No traumatic injury to teeth, oropharynx or nasopharynx, or trachea
Acceptable level of comfort
UNEXPECTED OUTCOMES
Intubation of esophagus or mainstem bronchus
No air leak or large air leak around ET tube, indicating tube size may be incorrect
Migration of ET tube
Inadequate oxygenation and ventilation
Hypoxemia from inappropriate bag or mask ventilation technique or poor intubation skills
Aspiration
Hemodynamic instability from medications or vagal stimulation
Vocal cord or tracheal trauma
Broken teeth
Inadequately managed pain or anxiety
DOCUMENTATION
Patient’s weight in kilograms
Time-out procedure, including verification of the correct patient, correct procedure, and correct site
Respiratory assessment findings before and after intubation, including vital signs, breath sounds, coughing, and tracheal secretions in the ET tube
Cardiovascular assessment including vital signs before and after the procedure
Route of intubation (oral or nasal)
Size of ET tube and presence of cuff
Medications administered for intubation
Confirmation of ET tube placement with indication of how placement was confirmed and depth of ET tube insertion (centimeters at teeth, gums, or nose)
Presence or absence of air leak
Pain assessment and specific interventions provided
American Heart Association (AHA), America Academy of Pediatrics (AAP). (2020). Part 8: Managing respiratory distress and failure. PALS: Pediatric advanced life support: Provider manual. Dallas: AHA. (Level I)
American Heart Association (AHA), America Academy of Pediatrics (AAP). (2020). Part 12: Managing arrhythmias. PALS: Pediatric advanced life support: Provider manual. Dallas: AHA. (Level I)
Crankshaw, D., McViety, J., Entwistle, M. (2014). A review of cuffed vs uncuffed endotracheal tubes in children. Pediatric Anesthesia and Critical Care Journal, 2(2), 70-73. doi:10.14587/paccj.2014.16 Retrieved September 21, 2023, from (classic reference)* (Level II)
Egbuta, C., Bragg, E.A., Kudchadkar, S.R. (2022). Chapter 127: Airway management. In J.J. Zimmerman and others (Eds.), Fuhrman & Zimmerman’s pediatric critical care (6th ed., pp. 1509-1534). Philadelphia: Elsevier.
Flasch, E. and others. (2019). Chapter 2: Pulmonary system. In M.C. Slota (Ed.), AACN core curriculum for pediatric high acuity, progressive, and critical care nursing (3rd ed., pp. 35-146). New York: Springer Publishing.
Groth, C.M., Acquisto, N.M., Khadem, T. (2018). Current practices and safety of medication use during rapid sequence intubation. Journal of Critical Care, 45, 65-70. doi:10.1016/j.jcrc.2018.01.017
Hairston, T.K., McNamara, L. (2024). Chapter 1: Emergency and critical care management. In C.C. Anderson, S. Kapoor, T.E. Mark (Eds.). The Harriet Lane handbook (23rd ed., pp. 2-35). Philadelphia: Elsevier.
Institute for Safe Medication Practices (ISMP). (2022). 2022-2023 Targeted medication safety best practices for hospitals. Retrieved September 21, 2023, from https://www.ismp.org/guidelines/best-practices-hospitals (Level VII)
La Vita, C.J. (2021). Chapter 37: Airway management. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 748-787). St. Louis: Elsevier.
MacKeil-White, K. (2023). Chapter 2: Pediatric differences. In ENPC:Emergency nursing pediatric course: Provider manual (6th ed., pp. 29-46). Burlington, MA: Jones and Bartlett Learning. (Level VII)
Nagler, J., Mick, N.W. (2023). Chapter 156: Pediatric airway management. In R.M. Walls and others (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (10th ed., pp. 2005-2015). Philadelphia: Elsevier.
Stein, M.L., Thomas, M., Watters, K. (2023). Chapter 36: Airway management. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 608-631). St. Louis: Elsevier.
*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.
Elsevier Skills Levels of Evidence
Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports
Clinical Review: Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CEN
