ASSISTING FOR ENDOTRACHEAL INTUBATION

INTRODUCTION

Endotracheal intubation (EI) is often an emergency procedure that’s performed on people who are
unconscious or who can’t breathe on their own. EI maintains an open airway and helps prevent
suffocation.In a typical EI, you’re given anesthesia. Then, a flexible plastic tube is placed into your
trachea through your mouth to help you breathe.The trachea, also known as the windpipe, is a tube
that carries oxygen to your lungs. The size of the breathing tube is matched to your age and throat
size. The tube is kept in place by a small cuff of air that inflates around the tube after it is inserted.

Your trachea begins just below your larynx, or voice box, and extends down behind the breastbone,
or sternum. Your trachea then divides and becomes two smaller tubes: the right and left main
bronchi. Each tube connects to one of your lungs. The bronchi then continue to divide into smaller
and smaller air passages within the lung.

Your trachea is made up of tough cartilage, muscle, and connective tissue. Its lining is composed of
smooth tissue. Each time you breathe in, your windpipe gets slightly longer and wider. It returns to
its relaxed size as you breathe out.

You can have difficulty breathing or may not be able to breathe at all if any path along the airway is
blocked or damaged. This is when EI can be necessary.

PURPOSE
1. The specific indications for intubation is,
a) When prolonged PPV is required.
b) When BMV is ineffective.
c) Meconium stained liquor.
d) When diaphragmatic hernia is suspected.
2. As a life saving measure for artificial ventilation.
3. To clear the airway of secretions and Meconium to ease or
reduce the workload of breathing
 SCOPE
All babies who need to be intubated as per the above
said indication.

EQUIPMENTS
1. Laryngoscope with blade and batteries (No.1- Term Newborn, No.0-
Preterm newborn, No.00-optimal for extremely preterm newborn. Straight rather
than curved blade is preferred).
2. Endotracheal tube of appropriate size (with inside diameters of 2.4, 3.0, 3.5and
4.0)
{Below 1,000gm and below 28 wks – 2.5 mm,1,000gm to 2.000gmor 28 to 34
wks- 3.0 mm, 2,000gm – 3,000gms or 34 to 38wks – 3.5mm, >3000gm or > 38
wks – 4.0mm}
3. Stylet to guide endotracheal tube (Optional).
4. Adhesive tape or dynaplast (1/2or ¾ inches or ET securing device). 5.
Médication (sédation, muscle relaxant, etc).
6. Lubricating jelly
7. Disposable syringe (required size).
8. Suction setup with tubing’s (required size) 10f or large suction catheter,
plus sizes 5f or 6f and 8f for suctioning the endotracheal tube.
9. Sterile towel
10. Stethoscope
11. Sterile gloves and
mask. 12. Magilles forceps
13. Scissor
14. Oral airway
15. Stethoscope (neonatal preferred).
16. Resuscitation bag and mask, oxygen tubing. Self inflating bag (must have
oxygen reservoir).
 PROCDURE

SL.NO. METHOD RATIONALE

1 Assess the babies’ heart rate, level of Provides a base line data to estimate patient’s
the consciousness & respiratory status. tolerance of procedure (may interfere with
insertion).

2 Assemble equipments. To economies time material and energy.

3 Ensure function of resuscitation Patient may require ventilator assistance

equipments and ventilator if required. during the procedure.

4 Make sure laryngoscope bulb is tightly If bulb is loose it may fall into airway during
attached and functioning. procedure.

5 Select the ET tube of appropriate size. To prevent leaking of air.

6 Open the ET tube and place it on a To prevent lower airway infection.

sterile field.

7 Lubricate distal end of the tube. Aids in insertions.

8 Insert Stylet into tube (according to Stiffens the soft tube and allows easy
the doctor’s preference). insertion.

9 Aspirate Stomach content if To prevent aspiration of stomach contents

nasogastric tube is in place. into lungs.

10 Assist the physician in gloving. For sterile technique.

11 Pre medication the baby if advised. Immobilize the baby.

12 Place the baby’s head in “sniffing” Upper airway is open maximally in position.
position (i e extended at the junction
of neck and thorax and flexed at the
junction of spine and skull).

13 Pre oxygenate the patient with ambu Reduces risk of respiratory distress.
bag and mask for 3mints.
14 Provide laryngoscope and ET tube to For assisting the doctor.
the physician.

15 After insertion of tube check if tube is To check for correct tube placement & air
in place by auscultation. entry.

16 Secure the tube with adhesive tape or Dislodgement of a tube with an inflated cuff
apply ET stabilization device. may damage the vocal cord.

17 Continue oxygenating the baby till To avoid hypoxia.

baby is attached to a ventilator.

18 Make the baby in comfortable

position.

19 Replace the all articles. For termination of the procedure.

20 Document the procedure ‘position of To have a legal evidence of the procedure

the tube at nose and assessment of the being carried out and to avoid duplication of
baby. procedure.
 AIRWAY MANAGEMENT

INTRODUCTION

You arrive on scene, walk into the home and find a mother sitting on the couch with a 1-year-
old child on her lap. She explains her daughter has been sick for several days, but today it
was much harder than usual to wake her up from a nap and, “She just isn’t acting like herself.

The girl appears limp in her mother’s arms and doesn’t look up at you. She appears
diaphoretic and her respiratory rate is approximately 8 breaths per minute. You look at your
partner, who appears just as worried about the patient as you are, and quickly begin taking
action.

Your partner hooks up the small patient to the monitor while you continue to assess her. She
barely wakes up from the feel of the blood pressure cuff and is lethargic. Her systolic blood
pressure is 90 mmHg, oxygen saturation is 84%, temperature is 101 degrees F, and heart rate
is 160. Her respiratory rate is very slow at 8 breaths per minute, and so you immediately
jump into airway and respiratory support.

ANATOMY & PHYSIOLOGY

The statement, “children are just little adults,” is a long-dispelled myth. In fact, pediatric
airways can be vastly different from the adult airways EMS providers more commonly
encounter. These differences are due to anatomical differences that amount to physiologic
changes that predispose the patient to airway obstructions.3 (See Figure 1.)
Figure 1: Pediatric vs. adult upper airway anatomy

Head: In the supine position, a young child’s head will cause a natural flexion of the neck due
to its large size. This neck flexion can create a potential airway obstruction. Patients usually
benefit from a towel to elevate the shoulders as well as someone to assist to help hold the
head, as it can be floppy.

Tongue: A child’s tongue is proportionally larger in the oropharynx when compared to adults,
and it may obstruct the airway due to this size.

Larynx: Located opposite C2–C3, a child’s larynx is higher up than in an adult, creating a

more anterior location that often results in difficulty when a provider attempts to visualize a
child’s airway.

Epiglottis: The adult epiglottis is flat and flexible, while a child’s is U-shaped, shorter and
stiffer. This makes it more difficult to manipulate and is a common reason providers can’t
visualize an airway with a curved blade in a pediatric patient.

Vocal cords: The anterior attachment of a pediatric patient’s vocal cords is lower than the
posterior attachment, which creates an upward slant, whereas in adults, the vocal cords are
horizontal. This concave shape may affect ventilation, and it’s important for providers to use
a jaw-lift maneuver to open the arytenoids.
Trachea: The trachea is shorter in pediatric patients, which increases the likelihood of right
mainstem intubation.

Airway diameter: A child’s airway is narrowest at the cricoid ring. As a result, secretions can
easily obstruct the airway, due to its small size, and even a small amount of cricoid pressure
can cause complete airway obstruction.

Residual lung capacity: Smaller lung capacity in pediatric patients means that a child can
become hypoxic more quickly than an adult. Providers should make sure to closely monitor
oxygen saturation and avoid prolonged periods without ventilation.

Pediatric Airway Positioning

The best way to set yourself up for airway success is by placing the pediatric patient in the
proper position. (See Figure 2.)

Figure 2: Proper and improper pediatric positioning

Neutral supine position showing flexion of the neck due to a child’s proportionally large
head.

Proper positioning of a towel under a child’s shoulders to counter neck flexion.

Improper positioning of a towel to counter neck flexion.

Taking into account anatomical considerations, start by placing the patient in the position of
comfort. Should you need to assist the child’s ventilation, lay them supine. You can counter
the flexion of the neck due to a child’s large head by placing a towel under the shoulders.
Remember, the goal is to place the patient in a “sniffing position.”

Another way to think of this is aligning the ear canal with the sternal notch. This position
isn’t only optimal for intubation, it’s also ideal when you’re ventilating with a bag-valve
mask (BVM).

Airway Opening & Suction

Start with the basics, and make sure the patient has an open airway. For any airway
management case, pediatrics included, remember that the least invasive maneuvers are often
the most beneficial. If your pediatric patient is hypoxemic, use the head-tilt chin-lift if you
don’t need to take C-spine precautions.

If there’s concern for C-spine injury, use a simple jaw thrust. Supplemental oxygen can be
applied if you believe the patient may benefit from it.

Taking these actions quickly and correctly is sometimes all you have to do to assist a
pediatric patient with oxygenation and ventilation. These simple airway opening techniques
can have a dramatic effect, so don’t underestimate them.
If a child is drooling or can’t handle secretions due to obstruction, help them use gravity to
expel secretions by placing them upright in a position of comfort or on their side. Laying
them down could be detrimental rather than helpful.

Remember, infants preferentially breathe through their nose and can have significant
respiratory distress from nasal secretions alone. Thus, suctioning these secretions can
decrease the work of breathing dramatically.

If you continue to see minimal chest rise or low oxygen saturation readings after performing
basic positioning and suction maneuvers, airway reinforcements will help provide additional
assistance.

Though the tongue can be an obstruction in any airway, you may find it particularly hindering
in pediatric airway management. Thus, inserting an oral or nasal airway can be extremely
helpful.

Remember that an oral airway is contraindicated if the patient is alert or has an intact gag
reflex, and that a nasal airway adjunct is contraindicated in severe central face trauma. If
needed, two nasal airways and one oral can all be placed in order to facilitate a patent airway.

Ventilation

Proper ventilation technique using a BVM is critical—potentially far more important than
any invasive airway procedures such as an extraglottic airway device or endotracheal
intubation. Ideally, this procedure is performed with two providers: one to ensure a good
mask seal and the other for bag squeezing.

The first focus should be on creating a good mask seal. This starts with selecting the correct
mask size based on the patient’s weight and ensuring it covers the mouth and nose. Be
mindful that in younger patients without teeth, it can be difficult to create a good seal because
there’s no platform for the mask to rest on.

Next, properly place your hands using an E-C grip if you’re the only one providing
ventilation support, or the T-E grip if there another provider is available. The T-E grip is
helpful because it keeps four fingers free to help keep the patient’s airway open using the jaw
lift.
During bagging, be mindful of not pressing the mask to the face but actually lifting the
patient’s face into the mask.

Lastly, focus on your target respiratory rate as well as the amount of compression on the bag.
Barotrauma can result due to excessive pressure being applied to the airway and this can
often occur due to provider stress and distraction.

Another pitfall that often results from provider stress is hyperventilating the patient, so
remember to focus on the rate you’re squeezing the bag during each ventilation. The ideal
respiratory rate for an infant up to 3 years is 20–30 breaths per minute. For older children
(ages 3 and up), the target respiratory rate is 16–20 breaths per minute.

Infants preferentially breathe through their nose and can have

significant respiratory distress from nasal secretions alone.
Invasive Techniques

Positioning and BVM-assisted ventilations will suffice for the great majority of situations
requiring airway management of pediatric patients; however, it may occasionally be
necessary or helpful to incorporate more advanced airway techniques requiring placement of
a tool into the airway itself.

Extraglottic airway devices (EGDs): EGDs are inserted blindly into the airway and have very
high success rates of providing oxygenation and ventilation with a minimum of initial and
ongoing training. EGDs bypass common challenges for achieving a tight mask seal, free
providers from performing two-person BVM ventilation, may be placed easily despite
ongoing CPR, and decrease the risk for gastric insufflation and aspiration as compared to
BVM.

Although these devices are being widely incorporated by EMS systems for all these reasons,
there’s still little data on their use for prehospital pediatric patients.

In adults, there are mixed results from prehospital studies on the risks and benefits of EGDs
compared to intubation in cardiac arrest,5,6 with larger studies now ongoing.7,8

There are a variety of EGDs now available on the market, some of which offer pediatric
sizes. A number of them also have a channel to facilitate gastric tube placement. The two
major categories are: 1) supraglottic devices (e.g., laryngeal mask airways) that effectively
move the facemask from the BVM inside the patient so that it sits over the glottis; and 2)
retroglottic devices that sit within the proximal esophagus and have two balloons—one in the
pharynx to keep air from exiting the mouth and one in the esophagus to keep air from
entering the stomach, directing gases into the airway by default. (See Table 1.)
Endotracheal intubation (ETI): ETI is ideal for airway protection because the occluded
trachea mostly prevents aspiration of saliva, blood and gastric contents into the lungs.

Though it’s an excellent means of oxygenation and ventilation, it’s not the only way to do so
and basic maneuvers should be attempted first before invasive procedures are performed.

Due to the success of non-invasive airway management, recent data has called into question
the utility and safety of ETI in all prehospital patient populations and is a particularly hot
debate in pediatrics.9

As a result, some large EMS systems have chosen to remove this skill from the paramedic
scope of practice, including Los Angeles County and Orange County, Calif., and the entire
state of New Mexico. (See sidebar, “Removing Pediatric ETI from Scope of Practice?”
below.)
Despite the controversies, there are still many prehospital providers who are performing ETIs
and this skill should be reviewed often. Anatomical differences in pediatric patients require
adjustments to your approach. This starts with choosing your equipment.

When picking equipment, you should keep in mind that pediatric patients generally have a
more U-shaped and stiffer epiglottis, making a Miller blade preferable.

The potential variation in the size of your patient is considerable, which can make ET tube
selection a challenge. Use of a Broslow tape or the Handtevy System can help providers more
quickly identify the blade and ET tube size.

When choosing your ET tube, there’s a choice between cuffed or uncuffed. It’s been the
school of thought for several years that cuffed ET tubes resulted in mucosal injury in
pediatric patients. However, newer ET tube cuff designs and monitoring of ET tube pressures
have minimized this risk. Some research has shown no difference in post-extubation stridor
rates between uncuffed vs. modern cuffed ET tubes in pediatric patients.10 However, long-
term consequences haven’t been studied.

Lastly, inexperience in the management of pediatric airways often leads to higher stress
resulting in increased difficulty. Pediatric EMS calls account for only 7–13% of all calls. Of
these, only 0.3% required intubation.1 Simulation training and keeping up to date on pediatric
airway skills are one way to reduce the high stress of pediatric intubation and may result in
increased proficiency.

Video laryngoscopy (VL): Several VL devices have been introduced over the last decade to
assist with ETI, and they’re generally considered to improve intubation success and aid in
teaching ETI technique. By projecting the intubation view onto a screen, VL allows for others
to provide real-time assistance and the option to record the experience for quality
improvement.

Larger VL devices have generally been used in the hospital, but small, portable options
geared toward prehospital providers are now readily available and have been shown to aid in
more successful first pass intubation attempts in adults. 11–13 (See Table 2, pp. 35–36, for an
overview of currently available devices.) Direct sunlight can make screen visualization
difficult with some VL devices and this is important to keep in mind when using them in the
prehospital setting.
Surgical vs. needle cricothyrotomy: In the rare instance where you can’t oxygenate a patient
via less invasive methods, a cricothyrotomy may be indicated (but performed only if it is
within your scope of practice).

There are two broad categories of cricothyrotomy: surgical and needle. For many pediatric
patients a surgical airway is contraindicated because smaller cricothyroid membranes and a
funnel-shaped, more compliant pediatric larynx can lead to an inadvertent incision of the
larynx as well as post-surgical complications such as subglottic stenosis.3

Textbooks vary considerably regarding the age cutoff for surgical cricothyrotomy, but most
agree that it is not indicated for patients less than 8 years of age.3 On the other hand, for
patients over 12 years old, the anatomy will generally permit surgical cricothyrotomy—keep
in mind it may not be included in your scope of practice. Needle cricothyrotomy usually
allows for oxygenation, but ventilation will be less than ideal. This procedure is generally
utilized to keep the patient alive until a more definitive airway can be obtained.

The decision to perform a cricothyrotomy—either needle or surgical—is often the most

difficult part of the procedure. Regular practice helps to allay fears, as does planning ahead of
time whenever you anticipate a difficult airway by finding the anatomic landmarks, marking
the site and having the necessary equipment ready.

CONCLUSION

After you recognize the need to intervene in the patient’s airway, you place the child supine
and position a towel behind her shoulders such that she’s in good sniffing position.

You confirm with her shallow respirations that she has breath sounds bilaterally.
Supplemental oxygen and two-person BVM ventilation is started and the patient is loaded
into the ambulance.

En route, respirations continue to be adequately supported by BVM. You arrive safely at the
destination and transfer care to the ED team, who continues resuscitative efforts.

You and your partner debrief while cleaning your ambulance and prepare for the next call.
Turns out it wasn’t such a quiet Saturday afternoon after all.