Pediatric Endotracheal Tubes
Endotracheal Tubes in Pediatrics
Key Points
- Precise size selection is crucial for pediatric airway management
- Cuffed vs. uncuffed selection depends on patient age and clinical scenario
- Regular position verification and securing techniques are essential
- Proper depth placement varies by age and size
Pediatric endotracheal tubes (ETTs) are specialized airway devices designed for the unique anatomy and physiology of infants and children. Their proper selection and use are critical for successful airway management in pediatric patients.
Types of Pediatric ETTs
1. Cuffed ETTs
- Modern microcuff technology for minimal pressure
- Better seal for mechanical ventilation
- Reduced need for tube changes
- Monitoring of cuff pressure essential
- Particularly useful in:
- Poor lung compliance
- High airway resistance
- Risk of aspiration
2. Uncuffed ETTs
- Traditionally used in children under 8 years
- Less mucosal damage risk
- Larger internal diameter for same external size
- Better for short-term use
- Considerations:
- Higher fresh gas flow requirements
- Potential for larger air leak
- May need frequent size adjustments
3. Specialized ETTs
- RAE tubes (preformed tubes)
- North-facing for nasal intubation
- South-facing for oral intubation
- Used in facial/oral surgery
- Wire-reinforced tubes
- Resistant to kinking
- Used in position-dependent procedures
ETT Size Selection and Depth Guidelines
Size Calculation Formulas
- Uncuffed ETT size: (Age in years/4) + 4
- Cuffed ETT size: (Age in years/4) + 3.5
- Depth of insertion (cm): ETT size × 3
Age-Based Size Recommendations
- Premature neonates: 2.5-3.0mm ID
- Term newborns: 3.0-3.5mm ID
- 6 months: 3.5-4.0mm ID
- 1 year: 4.0-4.5mm ID
- 2 years: 4.5-5.0mm ID
- 4 years: 5.0-5.5mm ID
- 6 years: 5.5-6.0mm ID
- 8 years: 6.0-6.5mm ID
- 10 years: 6.5-7.0mm ID
Length/Depth Verification
- Depth markers should be at level of vocal cords
- Confirmation methods:
- Chest X-ray position (T2-T4)
- Equal bilateral breath sounds
- Appropriate CO2 detection
- Symmetric chest rise
Procedural Considerations
Pre-intubation Assessment
- Airway assessment
- Mallampati score if possible
- Neck mobility
- Mandibular space
- Previous airway history
- Equipment preparation
- Multiple tube sizes (0.5mm above/below calculated)
- Functioning laryngoscope
- Suction equipment
- Securing materials
Securing Techniques
- Adhesive tape methods
- Modified chevron technique
- Double Y-gauze method
- Commercial securing devices
- Regular position checks
- Documentation of lip/nare position
Ongoing Management
- Regular cuff pressure checks (if cuffed)
- Oral care protocols
- Position verification after movement
- Tube patency assessment
Complications and Management
Immediate Complications
- Trauma
- Dental injury
- Soft tissue damage
- Vocal cord injury
- Misplacement
- Esophageal intubation
- Endobronchial intubation
- Too shallow placement
Long-term Complications
- Subglottic stenosis
- Vocal cord dysfunction
- Tracheal granulomas
- Prevention strategies:
- Appropriate size selection
- Regular cuff pressure monitoring
- Minimal movement
- Proper humidification
