Clinical Guidance

Paediatric Critical Care:

Intubation Guideline
Summary
The guideline sets out the steps for safe intubation. It details the indications and preparation
for intubation and also the considerations to be taken if it is a high risk intubation. Information
and steps are also included to follow if there is a difficult intubation or ventilation situation. This
guideline can also be used outside of the intensive care setting e.g. ED/ ward areas.

Document Detail
Document type Clinical Guideline
Document name Paediatric Critical Care: Intubation Guideline
Document location GTi & Evelina Website
Version v1.0
Effective from 10th February 2021
Review date 10th February 2024
Owner Head of Service, PICU
Author(s) Jo Perkins (PICU and anaesthetics consultant)
Laura Cutler (fellow)
Approved by, date Evelina London Clinical Guidelines Committee, February
2021
Superseded
documents
Related documents Paediatric difficult airway management
Paediatric Critical Care: Securing of Endotracheal Tubes
PICU: Intubation Method (Grade 3/4 airways)
Keywords Intubation, Difficult intubation, oxygenation Evelina,
Paediatric, STRS, critical care, PICU
Relevant external
law, regulation,
standards
This clinical guideline has been produced by the South Thames Retrieval Service (STRS) at
Evelina London for nurses, doctors and ambulance staff to refer to in the emergency care of
critically ill children. This guideline represents the views of STRS and was produced after careful
consideration of available evidence in conjunction with clinical expertise and experience. The
guidance does not override the individual responsibility of healthcare professionals to make
decisions appropriate to the circumstances of the individual patient.
Glossary: GCS-Glasgow Coma Scale, SAD-Supraglottic airway device

Change History
Date Change details, since approval Approved by

ELCGC Ref: 21025e Review by:10th February 2024

Paediatric Critical Care: Intubation Guideline

Oxygenation is the most important factor. No CO2 Trace = Wrong Place

Indications for Intubation Preparation Difficult mask ventilation
A - Airway compromise . No
See Help Kids Check list • Optimise head position
B - Impending respiratory failure • Insert oropharyngeal airway
(hypoxia/hypercapnia/exhaustion) • Adjust cricoid pressure if used
PLAN A – 1st Intubation Attempt
C - Minimise oxygen consumption • Ventilate using 2 person
and optimise oxygen delivery technique
D - Decreased level of Failed intubation • Manage gastric distention
consciousness (GCS less than 8) Oxygenate via mask • Ensure adequate anaesthesia &
E – For procedures, temperature Consider SAD (LMA) muscle relaxation
control, sedation or pain Call for senior help • Check equipment
management • Insert SAD not > 3 attempts
Assessment of the patient 2nd Intubation Attempt • Call for senior help
• Is the airway open and clear? DAS difficult mask ventilation
• Is the patient breathing
Confirm adequate muscle relaxation
spontaneously? Cannot Oxygenate via SAD
And optimal head and neck position
• Is the patient sufficiently • Revert to face mask and attempt
Consider:
oxygenating with a mask or high flow to ventilate with 100% oxygen
•changing size of ETT/ blade
oxygen? •video laryngoscope/ bronchoscope • (See box above to optimise mask
If answer to any above is no – ventilation)
•bougie or stylet
optimise airway, ensure breathing is • Call for senior help
supported and ensure adequate • Consider upsizing SAD – no
oxygenation before proceeding to more than 1 attempt
Failed intubation
urgent Intubation as per HELP KIDS
Oxygenate via mask
check list
Consider SAD
Cannot Oxygenate Via mask or
Call for senior help
High Risk Intubations SAD – saturations <80% (or 15%
< baseline in cyanotic heart
PLAN B – Change to Senior disease) and falling and/or
History: discuss with family and look
Operator after 2 attempts bradycardia
on EPR/anaesthetic notes
• Difficult bag mask ventilation or • Attempt Intubation
intubation (C-L grade 2-4) Failed intubation • Consider video laryngoscope if
• Adverse reaction to anaesthesia or Not more than 2 attempts immediately available
family history of this Oxygenate via mask
Anatomical: limited mouth opening, Consider SAD
Can’t Intubate, Can’t Ventilate
neck stiffness, jaw protrusion Call for PICU consultant
Scenario (CICV)
• Obstructive or deforming head and and/or Anaesthesia
• FiO2 100% via mask with PEEP
neck lesions or surgery • Call for senior help – PICU /
• Clinical syndromes (Trisomy 21, PLAN C – Assisted
Anaesthesia / ENT
Pierre Robin, Hurlers etc) Intubation
• Get difficult airway trolley from
Airway obstruction: croup, Requires PICU
theatre
epiglottitis, foreign body, burns Consultant
• Optimise as per difficult mask
• Mediastinal mass highest risk (+/-) Anaesthetics/ENT
ventilation box
Pulmonary reserve limited: DAS unanticipated
• Consider SAD
Asthma, ARDS, chronic lung disease difficult intubation
• For CICV protocol and Front of
Cardiovascular instability neck access refer to Evelina
Aspiration risk: full stomach/ Paediatric difficult airway
delayed gastric empting management guideline
or
Do not proceed without advice
DAS CICV paediatrics
from PICU consultant Successful Failed Intubation
Intubation • Oxygenate via Troubleshooting (DOPES)
If intubation has been difficult • Confirm ETT mask • Displacement
Do not change the ETT unless position and • Consider SAD • Obstruction
discussed with PICU Consultant adequate • Discuss with • Pneumothorax
ventilation with Anaesthesia and • Equipment
Extubation should be undertaken in ETCO2 ENT for transfer to • Stomach
a controlled environment • Secure ETT theatre AND • Unusual diagnoses e.g.
• CXR Vascular rings or tracheal stenosis

Reference: APA DAS Paediatric Difficult Airway Guidelines 2015

ELCGC Ref: 21025e Review by:10th February 2024

ELCGC Ref: 21025e Review by:10th February 2024
SIDE B FINAL
FINALFAST PRE-FAST PRE-INTUBATION
INTUBATION CHECK - CHECK
FO - FOR ALL INTUBATIONS

Start here
Read aloud to team

How to Use: -
A FEW MINUTES ONLY
KIT SHOULD ALREADY BE PRESENT
TEAM FOCUS IN - QUIET
CLEAR COMMUNICATION
READ ALL 3 SECTIONS
CHALLENGE RESPONSE
e.g.“Mask” “Check!”

Caution should be taken to

ensure nothing is
introduced into the airway