Procedure summary: Endotracheal intubation in children

Preparation

Preoxygenate the patient with 100% inspired oxygen.

Provide bag-mask ventilation as needed.

Initiate continuous monitoring of heart rate, respiratory, pulse oximetry, and cycled noninvasive or intraarterial blood pressure.

Assemble appropriately sized equipment*.

Test the laryngoscope blade light.

If applicable, inflate and deflate the cuff of the endotracheal tube to ensure no leak.

Place a stylet in the endotracheal tube and put a slight "hockey stick" bend at the tip.

If no concern for cervical spine trauma, position the patient in the sniffing position^¶.

Have an assistant provide manual inline stabilization for patients with concern for cervical spine trauma^Δ.

Direct laryngoscopy^◊

Open the patient's mouth using the scissor technique or, in patients without cervical spine restrictions, extending the head.

Insert the laryngoscope blade into the right side of the mouth along the base of the tongue while following the natural contour of the oropharynx.

Sweep the tongue to the left side by advancing the laryngoscope into the midline of the hypopharynx.

Advance the laryngoscope blade and identify the epiglottis.

Visualize the glottic opening and vocal cords:

Straight blade - Position the tip of the blade under the epiglottis

Curved blade - Position the tip of the blade in the deepest portion of the vallecula

Pull upward on the laryngoscope handle at a 45 degree angle to expose the glottic opening. DO NOT rock the laryngoscope handle backward as this will limit the ability to pass the endotracheal tube and typically causes injury to the upper gums, teeth, or lip.

Endotracheal tube placement

While maintaining visualization of the glottic opening and vocal cords, advance the endotracheal tube horizontally from the right side of the mouth.

Once the endotracheal tube has passed approximately 1 to 2 cm through the vocal cords, remove the stylet.

Confirm tracheal placement with capnography and clinical findings.

Assess proper depth of insertion (eg, centimeter mark equal to 3 times the internal diameter of the endotracheal tube).

Secure the endotracheal tube.

Obtain chest radiograph to document proper endotracheal tube placement.

* Refer to UpToDate content on equipment sizing for pediatric endotracheal intubation and age-based formula for selecting endotracheal tube size (internal diameter in mm).

¶ Refer to UpToDate content on proper positioning for ventilation and intubation for children older than 2 years of age.

Δ Refer to UpToDate content on cervical spine motion restriction in children.

◊ During emergency endotracheal intubation in children, we suggest video laryngoscopy (VL), if available, rather than traditional direct laryngoscopy (DL). For pediatric intubations in children with normal mouth opening and without concern for cervical spine injury, we also prefer VL with standard geometry blades rather than indirect VL with acute angle blades. Refer to UpToDate topics on emergency endotracheal intubation in children and video laryngoscopy in children.

Graphic 64481 Version 4.0

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Procedure summary: Endotracheal intubation in children