‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
DPP
DEPARTMENT:
PEIDATRIC ICU
POLICY NUMBER:
PICU - 032
TITLE: ENDOTRACHEAL INTUBATION
SECTION:
CRITICAL CARE
NUMBER OF PAGES: 10
VERSION NUMBER: 1
APPROVAL DATE: 21/06/2021
EFFECTIVE DATE:
REVIEW DUE:
APPLIES TO: All MEDICAL STAFF
NURSES AND RT Therapy
17/06/2024
21/07/2021
1.0 PURPOSE
1.1 Endotracheal intubation usually requires at least two qualified Health Care
Professionals (HCP), one to insert the endotracheal tube (ETT) into the tracheal and
another person to assist. This policy elaborates pediatric endotracheal intubation
indications and the responsibilities of the assistant who may prepare and monitor the
patients, assemble the equipment required under direction of practitioner intubating,
act as an extra set of hands (especially when the vocal cords are being visualized and
immediately following tube placement), and ensure patient safety. A third HCP may
be needed for medication administration or other tasks as directed.
2.0 DEFINITION
2.1 Health Care Professionals (HCP) – Physician- Assistant, RN(N), RRT and RT. two
personnel must be present to perform intubation - one qualified in intubation and one
to assist.
2.2 Endotracheal intubation for the purpose of establishing an artificial airway due to
respiratory arrest or impending respiratory failure.
3.0 INDICATIONS:
3.1 Inadequate oxygenation or ventilation (Respiratory failure)
3.1.1 Respiratory failure may result from primary pulmonary disease,
or from other processes associated with respiratory
compromise:
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
3.1.2 Clinical evidence of respiratory failure includes:
3.1.2.1 Poor or absent respiratory effort
3.1.2.2 Poor color or cyanosis
3.1.2.3 Obtunded mental status
3.1.3 Supporting data, such as noninvasive monitoring of oxygen
saturation and end-tidal carbon dioxide (EtCO2), or partial
pressure of oxygen or carbon dioxide from blood gas analysis
can be helpful; however, ETI should not be delayed in patients
with clinical evidence of respiratory failure to obtain
such measurements
3.2 Inability to maintain and/or protect the airway
3.2.1 Patients in this category may exhibit the following findings:
3.2.1.1 Inability to phonate or produce audible breath sounds
despite respiratory effort (complete airway
obstruction).
3.2.1.2 Inspiratory, obstructive sounds with partial airway
obstruction that fails to improve despite repositioning,
airway maneuvers, or medical therapies.
3.2.1.3 Impaired mental status including head injured patients
with a Glasgow Coma Score (GCS) of ≤8 and patients
with systemic illness or poisoning because of the
increased risk of aspiration
3.3 Potential for clinical deterioration
3.3.1 Children whose condition will likely deteriorate, such as
those with thermal inhalation injuries or epiglottitis,
require early intubation in a controlled fashion.
3.3.2 Similarly, patients with sepsis may be intubated based
on their anticipated course, as well as to maximize
oxygen delivery and relieve energy expenditure related
to increased work of breathing
3.4 Prolonged diagnostic studies or patient transport
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
4.0 CONTRAINDICATIONS:
4.1 Assessment and management of the airway is the first priority in caring for acutely ill or
injured children. Thus, there are no absolute contraindications for ETI by appropriately
trained providers.
4.2 Relative contraindications are uncommon but do exist and primarily relate to the need to
move to a more controlled environment or to perform a surgical approach to the airway:
4.2.1 In order to preserve airway reflexes and spontaneous
respiratory efforts in case of a failed intubation, rapid sequence
intubation with neuromuscular blockade should be avoided in
patients who are known or expected to be difficult to intubate
and difficult to ventilate with bag and mask, without an
appropriate back up plan in place.
4.2.2 Patients with a known or suspected laryngeal fracture should
be intubated with caution because of the risk of further
disrupting a partial laryngeal transection, resulting in complete
loss of the airway.
4.2.3 High-risk intubations (eg, epiglottitis) are most safely
performed in the controlled environment of the operating room
whenever delay secondary to transport will not compromise
patient outcome.
4.2.4 Although very rare, the unstable surgical patient (eg,
penetrating trauma to the larynx or severely distorting facial
trauma) deemed to require a surgical airway should not have
airway efforts delayed by attempts at direct laryngoscopy and
ETI.
5.0 PRECAUTIONS DURING COVID-19 PANDEMIC:
Appendix I.
6.0 MATERIALS / SUPPLIES:
6.1 Airway management kit
6.2 Pediatric intubation tray
6.3 Suction equipment including Yankuer tip and straight suction catheter o appropriate
size.
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
6.4 Laryngoscope - handles curved and straight blades of appropriate sizes. Glidescope may
also be requested.
6.5 Syringes
6.6 Appropriate size and style of endotracheal tube (ETT). cuffed or un-cuffed for children.
NOTE: for Pediatrics, assemble ETT 0.5mm larger and smaller than size anticipated.
6.7 ETT tapes, ties, or commercially available holder.
6.8 Scissors
6.9 Mc Gill forceps (may be required)
6.10 Stylet – depending on size of ETT.
6.11 Water soluble lubricating jelly (optional)
6.12 Bag- valve mask (BVM) device and appropriate size mask and PEEP valve as
appropriate.
6.13 Stethoscope
6.14 Personal Protective Equipment: Mask with attached visor and sterile / non-sterile gloves
as required by the situation (based on a point- of – care risk assessment, the use of other
appropriate PPE such as a gown may be considered).
6.15 Direct ECG rhythm, SPO2 and ETCO monitoring.
6.16 Medications (as ordered).
6.17 Vascular access supplies if medication being used.
6.18 Oropharyngeal airway.
6.19 Cuff pressure monitor for cuffed ETT (if available).
6.20 Gastric tube of appropriate size for decompression, if necessary.
7.0 PROCEDURE
7.1 Prepare hand hygiene and DON appropriate PPE.
7.2 Ensure that equipment is in working order while maintaining cleanliness of equipment.
5.2.1 Test endotracheal cuff for proper inflation with appropriate syringe.
5.2.2 Test for proper function of laryngoscope.
5.2.3 Test suction equipment.
7.3 Explain procedure and risks to patient / family and obtain consent as appropriate for
situation.
7.4 Obtain patient history and NPO status as appropriate.
7.5 Prepare for ETT insertion:
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
ETT GUIDELINE – PREFERENCES
AGE
SIZE
CUFFED VS UNCUFFED
Newborn
3.0 – 3.5
uncuffed
6 months
3.5 – 4.0
cuffed
At 1 year
4.0 – 4.5
cuffed
At 2 years
4.5
cuffed
At 4 years
5.0
cuffed
At 6 years
5.5
cuffed
At 8 years
6.0
cuffed
At 10 years
6.5
cuffed
At 12 years
7.0
cuffed
7.5.1 Ensure direct ECG rhythm and SpO2 monitoring is in place and patient has patent
IV access. In event of Cardiorespiratory arrest, IV / IO access will be addressed
as soon as possible.
7.5.2 Perform hand hygiene. Prepare medication as ordered.
7.5.3 Position patient so HCP that is intubating has access to the head of the patient.
Remove headboard from bed or lower crib rail and position the bed / crib away
from the wall to allow access for 2 HCPs and assembled equipment. The
assistant should be positioned ideally to the right of the person inserting the ETT
and have ready access to appropriate intubating supplies.
7.5.4 Place patient supine unless otherwise directed or contra indicated.
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
7.5.5 Perform hand hygiene. Don clean gloves. Remove any false teeth, bridges, or
foreign objects such as body piercings, from the mouth and perform hand
hygiene.
7.5.6 Slightly extend head and flex neck (“sniff position”), unless contraindicated (e.g.,
C-spine precaution). To assist in maintaining sniff position, a small roll under
shoulders in pediatrics r under the head in adults, maybe useful.
NOTE: If the
sniff position is contraindicated, HCP assisting will provide jaw thrust
maneuver.
7.6 Assist with procedure:
7.6.1 Perform hand hygiene, Hyper – oxygenate as directed by supplying 100% (3-5
minutes for pediatrics) if spontaneously breathing. If not spontaneously
breathing provide 3-4 hyperoxygenation, hyperinflation breaths using BVM
device and oral airway. (If necessary) or head tilt /jaw thrust maneuvers to
optimize SpO2 as much as possible.
7.6.2 Pre-medicate patients as directed.
7.6.3 Suction oropharynx as requested by HCP intubating. After suctioning is complete,
remove gloves and perform hand hygiene and don a new pair of clean gloves.
7.6.4 Apply cricoid pressure as requested by HCP intubating. This is done by applying
and maintaining firm pressure downward on cricoid cartilage / thyroid to assist
in visualizing the vocal cords. Do not remove cricoid pressure until directed to
do so by HCP intubating or the ETT placement is confirmed in trachea and cuff
is inflated (if cuffed ETT utilized). Release of pressure prematurely may result
in emesis / aspiration.
7.6.5 Intubation attempts:
7.6.5.1 Pediatrics: should be limited to 30 seconds depending on patient’s
stability.
7.6.5.3 The patient is manually ventilated with BVM device using 100% oxygen
between attempts.
7.6.6 Monitor SpO2 and / or ECG for deterioration during attempts. Notify HCP
intubating if SpO2 drops to below 90% or ordered levels, heart rate is below
age-appropriate norm or rhythm changes.
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
7.6.7 Once the ETT has been inserted into the trachea, it will be held in place by the
HCP who intubated. The assistant, upon direction from the HCP intubating,
will then take a firm hold of the proximal part of the ETT and remove the
stylet, or other insertion device used (i.e., Bougies) being careful not to move
the tube itself. The assistant will then remove gloves, perform hand hygiene,
and don a new pair of gloves.
NOTE: If patient is biting on the ETT, a bite block may be inserted.
7.6.8 The ETCO2 adapter is laced onto the ETT, positive pressure breaths are
provided, and the cuff is quickly inflated using the minimal occlusive volume
technique by slowly injecting air into the cuff and listening with a stethoscope
over the trachea until no air leaked can be heard.
7.7 Immediately assesses ETT Placement following intubation:
7.7.1 ETCO2 (End Tidal Carbo Dioxide) device (Capnography) with CO2 and
waveform, or by color change on color-metric device.
7.7.2 Person inserting ETT reports sees the tube pass through vocal cords.
7.7.2.1 Auscultate over right and left lung apices and epigastrium. Breath sounds
should be heard over both lungs and no sounds from epigastrium.
7.7.2.1.1 PEDIATRICS: Auscultate peripheral lung fields (under
axilla) for equal breath sounds. If air is heard entering the
stomach and there is no ETCO2 confirmation and or
breath sounds in peripheral lung
fields, the ETT should be removed immediately and BVM
ventilation provided until patient is stabilized prior to next
intubation attempt.
NOTE: Air entry to one lung may be indicative of ETT
placement into a main stem bronchus Notify
intubating HCP for readjustment of ETT depth
and reassess.
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
5.7.3 Observe for clinical improvement (heart rate, SpO2, color). Insect for bilateral
symmetrical chest expansion.
NOTE: Observation for condensation on the inside of the tube during
exhalation is not a primary confirmation technique.
5.8 Firmly secure ETT with tape.
5.9 Connect patient to humidified oxygen source or mechanical ventilator.
5.10 Perform hand hygiene and remove PPE.
5.11 Ensure that chest c-ray is ordered and obtained.
5.11.1
Pediatrics:
ETT tip should be 1-2 cm above carina.
5.12 Document on appropriate record:
5.12.1
Name of HCP performing intubation
5.12.2
ETT Size, type, level of insertion in “cm” (upper lip in pediatrics), route of
insertion, person performing intubation, volume or pressure used to inflate
ETT cuff, presence of air leak.
5.12.3 Methods used to confirm tube placement, including capnography reading.
5.12.4 Patient’s tolerance before, during and after procedure including vital signs
(heart rate, BP, SpO2, ETCO2).
5.12.5 Assess patient’s respiratory status (i.e., rate, rhythm, lung sounds, need for
suctioning / presence of secretions).
5.12.6 If CXR done.
5.12.7 On medication record. Medications used, including double signatures for
checking high alert medications.
5.12.8 Oxygen percentage and ventilator parameters if patient mechanically
ventilated following intubation on appropriate record.
5.12.9 If patient was a difficult intubation.
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
8.0 APPENDIX I
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫مستشفى الوالدة واألطفال بتبوك‬
Kingdom of Saudi Arabia
Ministry of Health
Maternity and Children Hospital
Tabuk Region
9.0 REFERENCE
9.1 Internet Research , Rady Children Hospital on Endotracheal Intubation
9.2 Internet Research Saskatoon Health Region Endotracheal Intubation Policies
and Procedures
9.3 Emergency endotracheal intubation in children - UpToDate
Approvals:
NAME AND POSITION
SIGNATURE
DATE
Dr. Mostafa Moheb
Quality Coordinator
Prepared by:
Eman Albalawi
PICU Head Nurse
Nojoud Hamad Al Anezi
Nursing Director
Reviewed by:
Dr. Hesham Sabri
Head PICU Department
Dr. Alaa Alyasi
Medical Director
Mona Ali Alatawi
QMPS Director
Approved by:
Mr. Hameed Saleem Al-Megbali
Hospital Director
TITLE
ENDOTRACHEAL INTUBATION
POLICY
TYPE
DPP
POLICY NUMBER
PAGE
PICU -032
1 of 10