1. Rapid Sequence Intubation • A patient who needs intubation may be awake. • Need for airway control may necessitate intubation. • RSI paralyzes the patient to facilitate endotracheal intubation.

2. Rapid Sequence Intubation

3. Pediatric Orotracheal Intubation

4. The Pediatric Airway • Anatomical Differences • Smaller and more flexible than an adult • Tongue proportionately larger • Epiglottis floppy and round • Glottic opening higher and more anterior • Vocal cords slant upward, and arecloser to the base of the tongue • Narrowest part is the cricoid cartilage

5. Pediatric Intubation • A straight laryngoscope blade is preferred for most pediatric patients. • Selecting the appropriate tube diameter for children is critical. • ETT size (mm) = (Age in years + 16) ÷ 4 • Matching it to the diameter of the child’s smallest finger • Use non-cuffed endotracheal tubes with infants and children under the age of 8 years.

6. Size Considerations

7. Ventilate the child © Scott Metcalfe

8. Prepare the equipment © Scott Metcalfe

9. Insert the laryngoscope © Scott Metcalfe

10. Visualize the child’s larynx and insert the ETT © Scott Metcalfe

11. Ventilate, inflate the ETT cuff (if it is a cuffed tube), and auscultate © Scott Metcalfe

12. Secure the tube © Scott Metcalfe

13. Confirm placement with an ETCO2 detector or waveform capnography © Scott Metcalfe

14. Reconfirm proper ETT placement © Scott Metcalfe

15. Ventilation of Pediatric Patients • Mask seal can be more difficult • Bag size depends on age of child • Ventilate according to current standards • Obtain chest rise and fall with each breath • Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement

16. Nasotracheal Intubation

17. Nasotracheal Intubation • “Blind” procedure without direct visualization of the vocal cords • Indications include: • Possible spinal injury • Clenched teeth • Fractured jaw, oral injuries, or recent oral surgery • Facial or airway swelling • Obesity • Arthritis preventing sniffing position

18. Nasotracheal Intubation • Contraindications • Suspected nasal fractures • Suspected basilar skull fractures • Significantly deviated nasal septum or other nasal obstruction • Cardiac or respiratory arrest

19. Nasotracheal Intubation • Advantages • The head and neck can remain in neutral position • It does not produce as much gag response and is better tolerated by the awake patient • It can be secured more easily than an orotracheal tube • The patient cannot bite the ETT

20. Nasotracheal Intubation • Disadvantages • More difficult and time consuming • Potentially more traumatic for patients • Tube may kink or clog more easily • Greater risk of infection • Improper placement more likely • Requires that patient be breathing

21. Nasotracheal Intubation

22. Field Extubation • Field extubation may be indicated when: • The patient is clearly able to maintain and protect his airway. • The patient is not under the influence of sedatives. • Reassessment indicates the problem that led to endotracheal intubation is resolved. • Consider the high risk of laryngospasm

23. Esophageal Tracheal Combitube • A dual-lumen airway • The longer, blue port (#1) is the proximal port • The shorter, clear port (#2) is the distal port, which opens at the distal end of the tube • Two inflatable cuffs • 100-mL cuff just proximal to the distal port • 15-mL cuff just distal to the proximal port

24. ETC Airway Esophageal Placement

25. ETC Airway Tracheal Placement

26. Esophageal Tracheal Combitube • Advantages • Provides alternate airway control • Insertion is rapid and easy • Does not require visualization of the larynx • Pharyngeal balloon anchors the airway • Patient may be ventilated regardless of tube placement • Significantly diminishes gastric distention • Can be used on trauma patients • Gastric contents can be suctioned

27. Esophageal Tracheal Combitube • Disadvantages • Suctioning tracheal secretions is impossible when the airway is in the esophagus. • Placing an endotracheal tube is very difficult with the ETC in place. • It cannot be used in conscious patients or in those with a gag reflex.

28. Esophageal Tracheal Combitube • Disadvantages • The cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia. • It does not isolate and completely protect the trachea. • It cannot be used in patients with esophageal disease or caustic ingestions. • It cannot be used with pediatric patients.

29. Esophageal Tracheal Combitube Click here to view a video on ETC.

30. Pharyngo-Tracheal Lumen Airway • Two-tube system: • Proximal cuff seals oropharynx • Distal cuff seals either the esophagus or the trachea • Advantages • Disadvantages

31. Laryngeal Mask Airway • Has an inflatable distal end that is placed in the hypopharynx and then inflated • Blind insertion • Disadvantage: • Does not isolate trachea

32. Intubating Laryngeal Mask Airway • It is designed to facilitate endotracheal intubation. • An epiglottic elevating bar in the mask aperture elevates the epiglottis. • Tube is directed centrally and anteriorly. © LMA North America

33. Cobra Perilaryngeal Airway • Similar to the laryngeal mask • Supraglottic airway • “Cobra head” of the airway holds both the soft tissue and the epiglottis out of the way © Engineered Medical Systems, Inc. Indianapolis, IN

34. Ambu Laryngeal Mask • Supraglottic, single-use, disposable airway • Features a special curve that replicates the natural human airway anatomy © Ambu Inc. Baltimore, MD

35. King LT Airway • Alternative airway • Large silicone cuff that disperses pressure over a large mucosal surface area • Stabilizes the airway at the base of the tongue ©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana

36. Foreign Body Removal Under Direct Laryngoscopy • Removing an obstructing foreign body using Magill forceps or a suction device • You should carry out basic life support maneuvers first. • If these fail to alleviate the obstruction, direct visualization of the airway for foreign body removal is indicated.

37. Foreign body removal with direct visualization and Magill forceps

38. Surgical Airways • You should use surgical airway procedures only after you have exhausted your other airway skills: • Needle cricothyrotomy • Surgical cricothyrotomy

39. Surgical Airways • Indications • Massive facial or neck trauma • Total upper airway obstruction • Contraindications • Inability to identify anatomical landmarks • Crush injury to the larynx • Tracheal transection • Underlying anatomical abnormalities

40. Needle Cricothyrotomy • Transtracheal jet insufflation is required • Complications: • Barotrauma from overinflation • Excessive bleeding due to improper catheter placement • Subcutaneous emphysema • Airway obstruction • Hypoventilation

41. Anatomical Landmarksfor Cricothyrotomy

42. Locate/palpate cricothyroid membrane

43. Correct position for puncture

44. Advance the catheter over the needle

45. Cannula properly placed in trachea

46. Jet ventilation withneedle cricothyrotomy

47. Open Cricothyrotomy • It is preferred to needle cricothyrotomy when a complete obstruction prevents a glottic route for expiration. • Its greater potential complications mandate even more training and skills monitoring. • Contraindications: • Includes children under 12

48. Open Cricothyrotomy • Cricothyrotomy Complications: • Incorrect tube placement into a false passage • Cricoid and/or thyroid cartilage damage • Thyroid gland damage • Severe bleeding • Laryngeal nerve damage • Subcutaneous emphysema • Vocal cord damage • Infection

49. Locate cricothyroid membrane

50. Stabilize larynx and make a 1–2 cm vertical skin incision over cricothyroid membrane