Intubation

CLINICAL GUIDELINES

A physician, nurse anesthetist, or advanced practice registered nurse (APRN) who has received special training performs intubation. In some states, a trained respiratory therapist, paramedic, or emergency medical technician may perform intubation.
A registered nurse (RN) or licensed practical nurse (LPN) assists in this procedure by providing support to the individual who will be intubating the child and being responsible for monitoring the status of the child before, during, and after the procedure. Pediatric Advanced Life Support (PALS) training is desirable.
Intubation is a means to provide a patent airway to facilitate mechanical ventilation and to facilitate pulmonary toilet.
Intubation is indicated when an infant or child experiences actual or potential loss of a patent airway, is in danger from aspiration, has no spontaneous respiration or inadequate ventilation or oxygenation, is in respiratory distress or failure, or is having surgery requiring anesthesia.

EQUIPMENT

Intravenous (IV) access
Sedatives and paralytics as ordered by a healthcare prescriber
Cardiac and apnea monitors
Pulse oximeter
Stethoscope
Gloves, masks, gowns, and goggles for standard precautions
Length-based resuscitation tape (LBT)
Endotracheal tubes (ETTs) of various sizes, cuffed and uncuffed. Tubes with an internal diameter (ID) 0.5 mm smaller and 0.5 mm larger than the child’s estimated size should be available
Laryngoscope with curved and straight blades
Extra light bulbs for laryngoscope
Self-inflating resuscitation bag with mask connected to oxygen tubing and flowmeter and oxygen source (must be capable of delivering 100% oxygen)
McGill forceps (for nasotracheal intubation only)
Stylet
Soft restraints or safety devices
Suction with Yankauer or large, rigid suction catheter
Securement device or tape cut for securing the tube
Tincture of benzoin (optional to enhance adhesion of tape to secure tube)
Oropharyngeal airway (if needed)
CO₂ detector
Ventilator
Nasogastric tube

CHILD AND FAMILY ASSESSMENT AND PREPARATION

See Chapter 92 for general procedural guidelines.
If possible, given the child’s condition, discuss the process of intubation with the child and the family. Discuss suctioning, the inability to talk, and that the child will be restrained to prevent him or her from pulling out the tube. If this is a nonemergent situation, discuss an alternative means of communication while the child is intubated. Picture boards or alphabet charts may be used to help the child communicate.

caREminder

If family members are not present during the procedure, communicate with them immediately after the intubation and reassure them about the status of the child. Allow the family to return to the child’s bedside as soon as possible.
If family members stay with their child during the procedure, explain intubation purpose and process. If possible, assign a staff person to support the family throughout the procedure. Allow family members to
comfort the child even if the child is in a nonresponsive state.
Before intubation, assess the child’s mouth for loose teeth. Teeth may become dislodged during the procedure and become a potential risk for aspiration.
Obtain vascular access before initiating the procedure. If vascular access is not possible to obtain, intraosseous access should be secured (see Chapters 53 and 63).

Airway control is the first priority in an emergency situation. In such cases, obtaining airway access should not be delayed while attempts to start an IV are being made.

PROCEDURE
Preparing for Intubation

Steps	Rationale/Points of Emphasis
1 Notify the healthcare prescriber of the necessity for the procedure. A respiratory therapist, an RN, and the healthcare provider intubating the child should be present.	Performance of the procedure by qualified personnel increases successful outcomes. The physician, nurse anesthetist, or nurse practitioner performs the procedure; the respiratory therapist assists in managing the airway; and the nurse monitors the child’s status and suctions and tapes the endotracheal tube (ETT).
2 Verify that the child has a patent IV line for administration of sedatives, paralytics, and emergency drugs.	IV access is needed should the child experience cardiac arrest during intubation. Emergency medications can also be delivered by the intraosseous route or by the ETT once it is verified to be in place.
3 Perform hand hygiene.	Reduces transmission of microorganisms.
4 Connect the child to cardiac/apnea monitors and pulse oximeter. Monitor the child’s heart rate, respiratory status, and oxygenation status before, during, and after the procedure.	Allows ongoing assessment of the child for any changes in heart rate, respiratory rate or function, oxygen saturation, or level of consciousness.
5 Use a length-based resuscitation tape (LBT) to determine the correct sizes for equipment and the proper doses of medications during pediatric resuscitation.	LBT are more accurate than age-based formulas for estimating ETT size and medication dosages for children up to approximately 35 kg.
6 Gather and assemble equipment, and check all equipment before the intubation procedure to ensure proper function.	Promotes efficient time management and provides an organized approach to the procedure.
6a Turn the suction on to between 80 and 100 mm Hg, and connect the Yankauer.	Suction equipment should be readily available to manage aspiration and to assist in visualization of the vocal cords.
6b Connect the self-inflating bag to an oxygen source with the flowmeter at 10-15 L/minute of 100% oxygen.	The self-inflating bag should have the ability to deliver 100% oxygen to oxygenate the child effectively. Neonatal-sized (250-mL) resuscitation bags are discouraged except for use with premature infants. A bag with a volume of at least 450 L/minute is recommended for term neonates and infants. An oxygen flow rate of at least 10 L/minute is required with the pediatric resuscitation bag and 15 L/minute with the adult-sized bag.
6c Select O₂ mask to use for bag-valve mask ventilations.	Bag-valve mask ventilations are necessary before the intubation procedure and possibly during the procedure if the intubation attempt is lengthy and the child requires oxygenation. Maintaining an appropriately sized mask at the bedside also is needed in the event of accidental extubation.
6d Attach the laryngoscope blade to the handle and check that the light bulb is tightly attached and functional (see Figure 58-1).	A light source is needed to ensure good visualization of the esophagus and vocal cords.
	caREminder
	Curved or straight laryngoscope blades can be used. Ask the intubating practitioner which he or she prefers (Figure 58-1). A light bulb that is not screwed in tightly may detach from the blade during the procedure.
Figure 58-1 Laryngoscope blades may be either curved or straight.
6e Obtain McGill forceps for nasopharyngeal intubation.	The McGill forceps is used to advance the ETT from the back of the throat during nasal intubation.
7 Select an uncuffed or cuffed age-appropriate ETT per the intubating provider’s orders. Several methods can be used to select the size. Use of LBT is recommended for children up to 35 kg. If LBT is not available, use recommended standard sizes based on age:	If the ETT is too large and an air leak is not present, damage may occur to the surrounding tissues from excessive pressure.
7a Uncuffed tube for infants up to 1 year = 3.5 mm ID Uncuffed tube for child aged 1-2 years = 4.0 mm ID	caREminder
	Cuffed tubes are typically used as it is hypothesized that in uncuffed tubes, due to lack of a substantial submucosal layer in the glottic and subglottic regions, shearing damage occurs, particularly with movement of an infant’s head and neck.
7b Cuffed tube for infants up to 1 year = 3.0 mm ID Cuffed tube for child age 1-2 years = 3.5 mm ID
7c The following is a quick formula for determining uncuffed tube size for children older than 2 years:	This is a very rough estimate for selection of an ETT and should only be used in emergency situations.
7d The following is a quick formula for determining cuffed tube size for children older than 2 years:	This is an instantaneous guide for determining the child’s airway size based on body size and can be used in emergencies where length-based tapes or other ETT size guides are not available.
7e If a cuffed tube is selected, inflate the cuff to make sure it assumes a symmetric shape and holds the volume without leaking and then deflate maximally.	In circumstances such as poor lung compliance, high airway resistance, or a large glottic air leak a cuffed tube may be preferable. Cuffed tubes may decrease the risk of aspiration. Follow manufacturer’s instructions for desired cuff pressure (usually less than 20-25 cm H₂O).
7f The correct size of an uncuffed ETT should allow for an air leak.	Absence of an air leak may indicate that the tube is too large, that the cuff is inflated excessively, or that a laryngospasm is occurring around the ETT. These conditions may lead to excessive pressure on surrounding tissue. A tube that is too small in diameter will allow too much air leakage around the tube and thus provide ineffective ventilation of the child.
8 Insert the stylet into the ETT, ensuring the tip does not extend past the distal end of the tube. With the stylet in place, the tube can be shaped into the desired configuration.	The stylet supports the tube, making it firmer and easier to insert and direct. Damage to the vocal cords can occur if the stylet protrudes from the distal end of the tube.
9 Cut tapes for securing the ETT after insertion or obtain appropriately sized securement device.	Having the equipment ready in advance prevents unnecessary delays during the procedure.