DIFFICULT INTUBATION

Paediatric Intensive Care Unit
Starship Children's Hospital
DIFFICULT INTUBATION
Assessment
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Check mouth opening / loose teeth/ pathology that may render intubation difficult
Length & mobility of neck
Check mandible. Is the distance between genu and the hyoid bone normal (one
fingerbreadth in infants, three in adolescents)?
When the patient’s mouth is wide open, can you see the uvula and the palatoglossal
arch completely? If these structures are partly hidden by the tongue, intubation may be
difficult
Plan
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Get help – specialist paediatric anaesthetist +/- ENT specialist
Do not give intravenous barbituates/propofol or muscle relaxant drugs
Prepare a variety of laryngoscope blades, ETTs, stylets and oropharyngeal airways
Induce anaesthesia with sevoflurane & N2O. Deepen anaesthesia with sevoflurane in
oxygen. Establish intravenous infusion. Consider atropine 0.02 mg/kg
Maintain spontaneous respiration with CPAP
When patient deeply anaesthetised, consider topical lignocaine to cords/pharynx. This
decreases incidence of laryngospasm during attempts to visualise glottis.
Have assistant manipulate larynx to good position during intubation.
If glottis not visualised but bag mask ventilation is possible:
Consider
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Use of laryngeal mask only
Intubation through laryngeal mask, bougie techniques
Discontinue anaesthesia and wake patient up
Use alternative techniques to direct laryngoscopy (fibre-optic scope, lightwand, blind
intubation, Combitube, transtracheal airway)
If glottis not visualised and bag mask ventilation is not possible:
Consider
1.
Insert a laryngeal mask to ventilate the lungs
2.
If ventilation is possible, consider
- wake up patient
- attempt blind nasal/ fibre-optic
- intubation through laryngeal mask, bougie techniques
- Combitube in large patient
3.
If ventilation is not possible, urgently establish transtracheal airway:
- retrograde intubation
- cricothyroidotomy
- tracheotomy
Author: Brian Anderson
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