ENDOTRACHEAL INTUBATION

AIRWAY ACCESS - ENDOTRACHEAL INTUBATION

(Please requests for assistance from the Anaesthetic Doctor if necessary)

Preparation :

• Bag and mask with high oxygen flow
• Laryngoscope
• Blades: straight for infant, curved for older child,
• size 0 for neonates, 1 for infants, 2 for children
• Endotracheal tube – appropriate size as shown
• Stylet (optional)
• Suction catheter and device
• Scissors and adhesive tape
• Pulse oximeter
• Sedation ( midazolam or morphine)
• Muscle relaxant (succinylcholine)

Note: The relative contra-indications for succinylcholine include increased intra-cranial pressure, neuromuscular disorders, malignant hyperthermia, hyperkalaemia and renal failure.

Size of ETT (mm):
2.5 for <1 kg
3.0 for 1-2 kg
3.5 for 2-3 kg
3.5-4.0 for >3 kg

Oral ETT length in cm for neonates : 6 + (weight in kg) cm

For children over 1 year: ETT size in mm = 4 plus (age in years / 4)

Oral ETT length in cm = 12 plus (age in years / 2)

Indications :

1. When bag and mask ventilation is insufficient
2. For prolonged positive pressure ventilation
3. Direct suctioning of the trachea
4. To maintain and protect airway
5. Diaphragmatic hernia (newborn)

Complications :

1. Esophageal intubation
2. Right lung intubation
3. Trauma to the upper airway
4. Pneumothorax
5. Subglottic stenosis

Procedure :

1. Position infant with head in midline and slightly extended.
2. Continue bag and mask ventilation with 100% oxygen till well saturated.
3. Sedate the child with IV midazolam (0.1-0.2 mg/kg) or morphine (0.1-0.2 mg/kg). Give muscle relaxant if still struggling (succinylcholine 1-2 mg/kg)
4. Monitor the child’s vital signs throughout the procedure.
5. Introduce the blade between the tongue and the palate with left hand and advance to the back of the tongue while assistant secure the head.
6. When epiglottis is seen, lift blade upward and outward to visualize the vocal cord.
7. Suction secretion if necessary.
8. Using the right hand, insert the ETT from the right side of the infant’s mouth, a stylet may be required.
9. Keep the glottis in view and insert the ETT when the vocal cords are opened till the desired ETT length while assistant applies cricoid pressure.
10. If intubation is not done within 20 seconds, the attempt should be aborted and reventilate with bag and mask.
11. Once successfully intubated, remove the laryngoscope and hold the ETT firmly with left hand. Connect to the self-inflating bag and positive pressure ventilation.
12. Confirm the ETT position by looking at the chest expansion, listen to lungs air entry and also the stomach.
13. Secure the ETT with adhesive tape.
14. Connect the ETT to the ventilator.
15. Insert orogastric tube to decompress the stomach.
16. Check chest radiograph.