Pediatric Airway Series: Part 2 – Preparing for Intubation

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October 10, 2017 by Agnes Usoro

Non-Invasive Ventilation (NIV) should be utilized to prevent Intubation

  • NIV in the pediatric population has really only been studied with bronchiolitis.
  • Primary forms include Nasal continuous positive airway pressure and High flow nasal cannula although Bilevel positive airway pressure (BiPAP) has been used in children with chronic conditions associated with respiratory insufficiency.
  • But as with adult populations with congestive heart failure and chronic obstructive pulmonary disease, providing positive pressure ventilation non-invasively can stave off the need for invasive ventilation.
  • But if at any point the child continues to have poor oxygenation, ventilation or mentation, the decision needs to be made for a more definitive airway.

Decision has been made to Intubate. What now?

  • There are “7 P’s” for Intubation to help outline a step-wise approach
    1. Preparation
    2. Pre-oxygenation
    3. Pre-treatment
    4. Paralysis and induction
    5. Protection and Positioning
    6. Placement of the ET tube
    7. Post-intubation management


We will discuss steps one (preparation) and two (pre-oxygenation) here:

  • Preparation and Pre-oxygenation are the two most important steps when it comes to intubating any patient. They improve success and allow cushion room in case the first attempt is not successful. Intubating is a life-saving procedure that needs to be approached methodically.



  • There are various acronyms to help with remembering the steps for Preparation, which is essentially gathering the supplies needed for a successful intubation. Example: SOAP ME Acronym
    • Suction
      • Oral suction equipment
      • Endotracheal suction equipment
    • Oxygen
      • Wall Oxygen or Oxygen tank
      • Oxygen delivery method for Pre-oxygenation
      • Bag-valve mask
    • Airway Equipment (including back-up equipment)
      • See Part 1 of Pediatric Airway Series
      • Always have the appropriate sized endotracheal tube + one size smaller
      • Always have Magill forceps if foreign body obstruction is suspected
    • Positioning
      • Remember anatomical differences in children
      • Elevation of the head is usually not required; Shoulder rolls instead are more helpful for aligning the oral, pharyngeal and tracheal axes
    • Medications
      • IV or IO access
      • 20 mL/kg normal saline bolus (to offset hemodynamic changes during RSI)
      • Pre-medications
      • Induction medication
      • Paralytic medication
    • EtCO2 and post-intubation Equipment
      • Ventilator
      • Post-intubation sedation
  • Concurrently, while running through your Preparation checklist, initiate Pre-Oxygenation even if the oxygen saturation is already 100%


  • Utilize non-invasive methods such as high-flow oxygen through a non-rebreather mask or high flow nasal cannula
  • Goal is to maintain an oxygen saturation of 100% prior to the initiation of intubation
  • This is NOT the time for bag-valve-mask ventilation if the child is breathing spontaneously
  • Intubation is an anxious process for both the provider and the child. Allowing the child to breath spontaneously without the anxiety of a face mask can help prevent dynamic airway obstruction
  • We will discuss bag-valve-mask ventilation once the child is induced and paralyzed in Part 3 of the Pediatric Airway Series


  • Tintinalli, J.E., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition.Section 12, Chapter 111

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