What’s the difference between an adult’s and child’s epiglottis?
Child- Omega shaped and floppy
Adult- Flat and firm
Indications for adult/ peds endotracheal intubation
- Need for prolonged artificial ventilation
- Inadequate vent support with BVM
- Cardiac and respiratory arrest
- Control of an airway in a patient without a gag reflex or cough
- Providing a route for drug administration
- Access to the airway for suctioning
- Relief of airway obstruction (only adults)
What’s the normal tube size for an adult?
Female- 7-8
Male- 8-9.5
What is the insertion distance in males and females?
Males- 22-25 cm
Females- 20-23 cm
How far above the carina should the ET tube be in adults and babies?
Adults- 2-5 cm above the carina (at T4 or 4th rib)
Babies- between T2-T3
How do we determine the depth of insertion for an adult?
Tube size x 3 (don’t go past 25)
Indications for neonatal /infant intubations
- To suction meconium
- PPV is not working
- Need for prolonged PPV
- To facilitate coordination of chest compressions and ventilation
- To facilitate the need to give epinephrine while establishing an IV
What are some special indications for intubation on infants?
- Extreme prematurity
- Surfactant administration
- Diaphragmatic hernia
The more premature the baby, the _________ the vocal cords appear.
Pinker
How do we find the size of the tube for peds?
(Age in years + 16) / 4
How do we find the depth of insertion for peds?
(Age/2) + 12 cm
What is the difference between a Mac and Miller blade?
Mac is curved and inserted into the vallecula. Miller is straight and lies beneath the epiglottis.
What is the vallecula?
The space between the base of the tongue and the pharyngeal surface of the epiglottis
What is the best way to know that you have inserted the ETT in the right place?
Bilateral breath sounds
How should the head be in an x-ray to confirm ETT placement?
Bed flat with head midline in a neutral position
What are some complications from intubation?
- Failure to establish a patent airway
- Failure to intubate the trachea
- Upper airway trauma, laryngeal and esophageal damage
- Aspiration
- Vocal cord paralysis
- Cervical spine trauma
- Infection
What indicates high risk post extubation stridor with the cuff leak test?
A leak of less than 110 mL
What are the two main complications of extubation?
Laryngospasm and glottic edema
What is the treatment for laryngospasm and glottic edema?
Laryngospasm - High FiO2, if worsens use muscle relaxant and reintubate
Glottic edema - Racemic epinephrine (cool mist)
What are some causes of glottic edema?
Traumatic intubation, oversized ET tube, poor ET tube maintenance
