Intubation - difficult
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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
- 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
- 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
- Insert a laryngeal mask to ventilate the lungs
- If ventilation is possible, consider
- wake up patient
- attempt blind nasal/ fibre-optic
- intubation through laryngeal mask, bougie techniques
- Combitube in large patient
- If ventilation is not possible, urgently establish transtracheal airway:
- retrograde intubation
Did you find this information helpful?
- Document type: Clinical Guideline
- Services responsible: Paediatric Intensive Care Unit
- Author(s): Brian Anderson
- Editor: John Beca
- Review frequency: 2 years
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