Most of our patients will be intubated prior to ICU arrival.  For children who need intubating in the unit, a senior clinician with experience with the paediatric airway should be present.  The ICU consultant on call should be informed if they are not already present.  There are several differences to be aware of:

  • Anatomy

    • Children have relatively large heads, and if on a pillow their necks will be over flexed.  It is usually necessary to remove the pillow, and sometimes place a folded blanket under the shoulders to achieve neutral alignment.  Over extending the head and neck can cause kinking and obstruction to soft airways and can make bag mask ventilation impossible.  Children have small mouths, large tongues and high anterior larynxes which can all make intubation challenging.  The epiglottis is long and floppy in babies, they are usually easier to intubate with a straight (miller) blade to lift the epiglottis.  A stylet in the ETT to mould a 'hockey stick' shape can make intubation easier.  Cricoid pressure is best avoided in babies and young children (no evidence it helps, and can be physically difficult to apply as well as obscuring view).


    • The initial intubation is oral, however converting to a nasal tube is preferred, as this is better tolerated and easier to secure.  The method of securement is outlined in the information folder on the paediatric trolley.  The trachea is short, so even if the ETT is correctly positioned on initial CXR, it is important to secure the tube firmly, and prevent excessive head movement (head extended = ETT high, head flexed = ETT low)


    • Both cuffed and uncuffed ETT's are available in the unit.  The default is an uncuffed tube, however in some situations e.g. noncompliant lungs, a cuffed tube may make ventilation easier – this should be discussed with the SMO on call.


  • Physiology

    • Young children readily become bradycardic in response to suxamethonium given for intubation; consideration should be given to pre-treatment with atropine (20mcg/kg, minimum 100mcg).  An alternative to suxamethonium is 1mg/kg rocuronium for intubation.  Children have higher metabolic rates than adults and lower FRC, and therefore desaturate rapidly.  Pre oxygenation and rapid securement of the airway is therefore crucial – ensure you can bag-mask ventilate the child prior to giving a long acting relaxant for intubation.  LMA's in appropriate sizes are also available in an emergency.
    AgeETT size*ETT length at lipETT length at nostrilLMA sizeSuction catheter size
    3 months3.5mm10121 (<5kg)
    1.5 (5-10kg)
    1 year4.0mm11141.5 (5-10kg)
    2 (10-20kg)
    >1 year4 + Age/412 + Age/215 + Age/22.5 (20-30kg)
    3 (30-50kg)
    2 X size ETT


    *ETT.  A leak should be present with PPV.  ETT can be uncuffed (usual) or cuffed (cuff usually left deflated) to ensure the right fit.

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    Page last reviewed: 14 May 2014