Preoxygenation

Pediatric patients are also significantly predisposed to hypoxemia, due to higher metabolic requirements and reduced functional residual capacity.⁸ According to the National Emergency Airway Registry for Children, 13 percent of all pediatric patients have desaturated prior to or during intubation, with nearly half of all difficult pediatric intubations included in that number.⁹

As soon as the team determines that RSI is required, the patient should be preoxygenated with 100 percent oxygen. If possible, the patient should be given five minutes of 100 percent oxygen on a nonrebreather mask, or eight vital capacity breaths to grant three to four additional minutes of apnea before hypoxemia sets in.⁷ In particularly difficult airways, organizations such as the Pediatric Difficult Intubation Collaborative recommend passive oxygenation via nasal cannula during the intubation attempt.¹⁰ Humidified, high-flow nasal cannula oxygenation during the patient’s apneic periods has also been shown to significantly delay the time to desaturation.⁹

Upper Airway Obstruction

Some physicians prefer using the straight Miller blade in patients younger than 4-5 years old, as it directly lifts the anteriorly shifted epiglottis to visualize the cords, while a curved Macintosh blade indirectly lifts the ligamentous connections of the epiglottis for cord visualization.⁸ In cases where ventilation with a face mask is warranted, an oral airway may be used to relieve any obstructions caused by posterior displacement of the tongue.⁸

Blade Selection

A wide range of conditions in pediatric patients, including syndromes such as Pierre Robin and Trisomy 21, can make it difficult to visualize the vocal cords.^11,12 In recent years, videolaryngoscopes (VL) designed for pediatric patients have become far more available on the market. VL blades may include options for standard direct laryngoscopy (DL) blades, such as the Miller and MacIntosh designs. Hyperangulated blades—designed specifically for VL intubation—are also growing in popularity.¹⁰ However, in infants weighing less than 5 kg, VL with a standard Macintosh or Miller blade appears to be associated with a significantly greater success rate than that achieved with hyperangulated blades.¹³

Some studies suggest there is no significant difference between these blades in the 1-24 month age group.¹⁴ However, other studies maintain that the Miller blade is significantly more effective in intubation in pediatric patients aged 2-6 years.¹⁵ In children younger than 2 years of age, the size 1 Miller may be used to lift the epiglottis, or a Macintosh blade may be used to lift the base of the tongue.¹⁶