Non-angulated VL blades have a reduced viewing angle that simultaneously makes passing an ET tube a less complex maneuver for the clinician.¹⁰ Similarly, the efficacy of VL versus DL remains controversial within the wider literature.¹⁰

In cases of severe upper airway obstruction, supraglottic airways such as the laryngeal mask airway (LMA) may be used.⁸ An LMA may temporarily secure the airway, while a bronchoscope is passed through the LMA into the patient’s trachea. Afterwards, the LMA may be removed and an endotracheal (ET) tube passed over the bronchoscope to intubate the patient.⁸

ET Tubes

ET tube insertion may be difficult due to the vocal cords being aligned in an anterior–inferior angle rather than the posterior-superior angle seen in adults. This increases the risk of the ET tube becoming obstructed or blocked by the vocal folds.⁸ The 2023 Pediatric Advanced Life Support (PALS) guidelines recommend the following formulas for ET tubes.¹⁷ Three times the tube size for ETT depth is also commonly used.¹⁸

In stressful situations in which calculations may be difficult, Broselow tape is also an effective measure to estimate ETT size.¹⁹

Cannot Intubate, Cannot Oxygenate

The most severe cases are referred to as a Cannot Intubate, Cannot Oxygenate scenario (CICO).¹⁰ If the patient cannot be intubated, mask ventilation should be optimized; then an LMA supraglottic airway should be attempted, followed by surgical airway.¹¹

For patients younger than 8 years, a surgical cricothyrotomy may be performed to create a space through which an ET tube may be inserted.⁷ Needle cricoidotomy is often difficult, due to the flexible cricoid and trachea in this population, as well as the small size of the neonatal cricothyroid membrane.^8,10 Cannula-based cricothyrotomy, is a potential alternative, particularly with products such as the Ventrain device.¹⁰

Dr. Turner originally trained at the Medical University of South Carolina, is an EM intern at Hershey Medical Center in Hershey, PA.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University at MetroHealth Cleveland Clinic in Cleveland, Ohio.

References

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17. United Medical Education. PALS Algorithms 2024. Updated 2024. Accessed September 15, 2024.
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