Endotracheal intubation of infants and children is felt by many to be easier than the same procedure in adults. There are, however, some differences related to a child's anatomy and proper sizing of equipment. Pediatric airway management is discussed in detail in Chap 11. A brief overview is provided here for perspective.

POSITIONING Hyperextension of the neck must be avoided by placing the child in the sniffing position prior to intubation. Also, the stretcher should be raised so that the child's head is at least at the level of the intubator's waist. All equipment should be located within easy reach of the team, including the bag-valve mask, oxygen source, monitoring equipment, and, perhaps most importantly, the suction device.

LARYNGOSCOPE BLADES For two reasons, the curved (MacIntosh) blade is rarely used in children who are younger than age 4. The relatively large and flaccid epiglottis is not effectively displaced by pulling on it indirectly from the vallecular space. Second, an exact-sized blade must be used to fit the curvature of the tongue. For these reasons, a straight (Miller) blade is preferred. The straight blade is inserted in the midline with the tip underneath the epiglottis such that the epiglottis is directly lifted up to allow tracheal visualization.

ENDOTRACHEAL TUBE Tracheal tube sizes vary with a patient's age. An often-quoted rule is that the correct internal diameter tube size is approximately the same size as the end of the patient's little finger. However, this tenet has been shown to not hold true. 67 The age-based formula (age + 16)/4 is a good predictor of correct endotracheal tube size for children. Uncuffed tubes are used for children up to 7 or 8 years old (tube size, 2.5 to 5.5 mm). The subglottic trachea (unlike in adults) is the narrowest spot of the tracheal apparatus and forms an adequate seal around the endotracheal tube in this age group. After this age, the vocal cords become the narrowest part to the airway and a cuff is needed to provide an adequate seal for positive pressure ventilation. One can almost always intubate with a laryngoscope blade that is too large and with a tube that is too small, but not vice versa.

SECURING THE AIRWAY Once a child has been intubated, one person should be assigned to hold the endotracheal tube in place until it is securely fastened. Confirmation of endotracheal intubation is similar to that in adults: adequate chest rise, symmetric breath sounds, capnographic or capnometric readings, 8 improved oxygenation, and clinical improvement.4 Because a young child has a small chest, listening to breath sounds in each axilla as well as over the stomach will minimize the chance of hearing sounds transmitted from the other lung.4 The tube should be taped to the upper lip and jaw, ideally from both sides of the face. Especially in small infants, small movements can easily displace the tube from the trachea into the esophagus. Tape or ties should not be wrapped around the head of a young child, because these can slide off the occiput and easily allow displacement of the tube. Mechanical ventilation is discussed in Breathing, which follows.

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