Pediatric Airway Series: Part 5 – Post Intubation Management

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March 15, 2018 by Agnes Usoro

Endotracheal Tube Confirmation

  • Confirm endotracheal tube placement with capnography or a colorimetric end-tidal carbon dioxide detector
    • < 15kg: Use a small sized CO2 detector
    • > 15kg: Use the standard, adult sized CO2 detector
  • Maintain continuous waveform capnography while the patient is intubated
  • Obtain a chest x-ray to confirm placement and depth
  • Be mindful that young children are at risk for displacing their ETT when their heads are extended, as well as lodging the tube deeper into their right main-stem when their heads are flexed

Vent Settings

  • For smaller children < 10kg, utilize Pressure-controlled ventilator settings
  • For larger children > 10kg, you can start them on Volume-controlled ventilator settings, although many pediatric units still preferentially utilize Pressure-controlled settings, as it is better for management of poorly compliant lungs
  • Recall that lung compliance is change in volume / change in pressure

    Pressure-Controlled Ventilator Settings

    Volume-Controlled Ventilator Settings

    You set the desired pressure settings. A set pressure is delivered at a set rate. The delivered tidal volume is determined by the preset pressure limits. A max pressure is set and when met, the vent will alarm to avoid barotrauma.

     

    Example of initial vent settings:

    RR (Resp Rate): 20-25 breaths/min

    PIP (Peak Insp. Pressure): 15-20 cmH2O

    PEEP (Positive End-Exp Pressure): 3-5 cmH2O

    FiO2: 100% (wean to goal 40-60%)

    I:E (Inspiration:Expiration) Ratio: 1:2

     

    Alarms:

    Pmax: 40 cmH2O

    Pplat (Plateau Pressure): 30 cmH2O

    The above settings will yield a Tidal Volume of 8-12 mL/kg

    You set the desired volume settings. A set volume is delivered at a set rate. The delivered pressure is determined by the preset volume. A max pressure is set and when met, the vent will alarm to avoid barotrauma.

     

    Example of initial vent settings:

    RR (Resp Rate): Based on patient’s age

    TV (Tidal Volume): 6-10 mL/kg

    PEEP (Positive End-Exp Pressure): 3-5 cmH2O

    FiO2: 100% (wean to goal 40-60%)

    I:E (Inspiration:Expiration) Ratio: 1:2

     

    Alarms:

    Pmax: 40 cmH2O

    Pplat (Plateau Pressure): 30 cmH2O


Sedation

  • Rapid sequence intubation (RSI) is commonly used for emergent intubations. Be aware that the volume of distribution is larger in pediatric patients due to their greater composition of adipose tissue. This results in longer duration of action for paralytics (especially Rocuronium and other longer-acting muscle relaxants). For this reason, provide adequate sedation and analgesia.
  • Commonly used infusions: Opioid (Fentanyl) + Benzodiazepine (Ativan, Versed).

References

 

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