Part 3 : Pediatric Airway Pearls​​

Potentially Hostile Airways for ETT

• Respiratory virus season is upon us ​
• This means an increase in calls for respiratory symptoms, including in the pediatric population​
• This #SWORBHPTips series will review some pediatric pearls based on anatomic differences in the pediatric airway and how to alter your management strategy to optimize your ventilation in this population​
• Post # 1 looked at optimal positioning, #2 looked at airway patency technique​
• This post will examine the management of the potentially hostile and difficult airway for intubation (ACP scope)

Large Epiglottis, Anterior airway = More difficult intubation​

• You may need to change your laryngoscopy technique in the pediatric population, especially in the younger populations​
  • Optimize positioning (see #SWORBHPTip Part 1)​
  • Large omega shaped epiglottis:​
    • May benefit from the Miller blade technique of picking up the epiglottis, rather than the Mac blade that slides into the vallecula​
      • Note: A Mac blade may still be utilized if more comfortable for the provider​
  • Superior, anterior airway:​
    • May benefit from a sharper anterior angle when advancing the ETT​
    • Routine use of cricoid pressure no longer recommended by AHA (for both adults and pediatrics)

Smaller airway = Sizing and Displacement Considerations

• ETT sizing approximation (CUFFED)​
  • Age/4 + 3.5​
• ETT depth estimation = ETT size x 3​
  • Gives a place to start: Can advance, or pull back as required, clinically​
• ETT smaller, shallower = Easier to displace with movement​
  • Hence, the prompt in the Orotracheal Intubation Medical Directive

Clinical Considerations

ETT placement must be reconfirmed immediately after every patient movement

Summary: Pediatric ETT Tips​

• In order to obtain the optimal views for laryngoscopy/ETT placement:​
  • Consider optimal patient positioning (see #SWORBHPTip Part 1)​
  • Consider utilizing a Miller blade for infants to help move the large, floppy epiglottis ​
  • Consider a more anterior/superior angle when advancing the ETT to account for the more anterior/superior positioning of the pediatric airway​
  • Size of cuffed ETT = (age/4) + 3.5​
  • Approximate ETT depth = ETT size x 3​
  • Reconfirm placement with every patient movement​

No additional resources available for this #SWORBHPTip.