•Resistance to passage of ETT:use ½ size smaller
•Cuff pressure to be kept < 20 cm H2O
Age
ETT ID
ETT Depth
Blade Stylet •Leak at <10cm H2O: exchange ETT for ½ size
larger
(mm)
(F)
(cm ATG/ATT)
•Smaller ETT= Raw
3 X ETT
•ETT follows chin. Pt position for care and CXR ++
* CXR to
confirm
important. Chin low=ETT low
<12 mo 3.5-4.0 uncuffed
10.5-12
Miller 0-1
•Shorter trachea= greater chance for extubation if
1 yo
3.5 cuffed
12-13.5
Miller 1-2
6
traction applied to ETT. Hold your tube with
2 yo
4.0 cuffed
13.5
reference to pt with any pt movement ,
4 yo
4.5 cuffed
15
Miller 2
suctioning, manual ventilation or transport!
6 yo
5.0 cuffed
16.5
Mac 2
•Depth of ETT recorded ATN, ATT or ATG
8 yo
6.0 cuffed
18
•Smaller ETTs may slip through tube holders10 yo
6.5 cuffed
19.5
14
consider taping ETT
12 yo
7.0 cuffed
21
Mac 3
Intubation1
teen
7.0-8.0 cuffed
21
Suction2
Suction
Pressure
(- mm Hg)
Age
< 1 yo
1-12 yo
>13 yo
Suction
Catheter
Instillation
Volume(ml)
60-80
80-120
100-150
0.5-1.0
0.5-3.0
0.5-5.0
*prn only*
(F)
2 x ETT ID
Ventilation Initiation Guidelines
Age
< 1 yo
> 1 yo
RR
25
20
Ti
(s)
0.35-0.55
0.5-1.0
Vt
(ml)
4-6 ml/kg
*
PEEP
(cm H2O)
5
*Admission weight (exceptions obese/ fluid overloaded)
*If no tubing compensation will need to  Vt
Remember anything added to the circuit
after the wye is DEADSPACE and may
be more significant with smaller Vt.
Problematic ETT Leak
•Line up depth marking on suction
catheter to depth marking on ETT.
•4.0 ETT and smaller suction a minimum
of Q8H
•Instillation volume is important to limit
and document in infants and small
children
•VAP protocols apply
•Ideally want PIP <25 cm H2O
•With  RR may need to Ti
•Consider Pressure ventilation to limit PIP
•Accept pH > 7.25 manipulate RR to achieve
• Accept PO2 > 60
•When MAP >16-18 consider APRV/ HFOV
•Want 8-9 posterior ribs inflation on CXR
•Wean to minimum PS of 8 for infants, 6 for
children
• Should have leak around ETT prior to extubation
IF NO LEAK with cuff deflated:
•Consider Dexamethasone pre-extubation
•Have epinephrine 1:1000 neb ready (0.5 ml/kg
up to max of 5 ml) post-extubation
-Choose pressure mode of ventilation
-Need to assess chest rise for adequate Vt
-Measured Vt’s inaccurate
-Pt position will affect leak
-Can pack around ETT with NS soaked nasal packing as
temporary fix if issues with CO2/O2. DO NOT CUT and tape to
face.
-Exchange ETT for larger size
Normal Vital Signs1
Age
<12 mo
1-3 years
3-5 years
6-12 years
13-18 years
RR
BP*
HR awake
HR asleep
30-60
24-40
22-34
18-30
12-16
87-105/53-66
95-105/53-66
95-110/56-70
97-112/57-71
112-128/66-80
100-190
80-160
70-140
60-110
60-90
75-160
60-90
60-90
60-90
50-90
•*Lower limit of SBP
=70 + (2 x age in years)
•Infants and small children don’t like
strangers. RR, BP and HR will . Evaluate
prior to entering room if possible
•Respiratory failure is 1° cause of cardiac
collapse. Intervene early.
•Children have large compensation
capacity. Must recognize shock early. Too
late once decompensated.
Signs of  WOB
•↑RR, Apnea
•Nasal flaring
•Head bobbing
•Seesaw respirations
•Accessory muscle use
•grunting
•Chest retractions
•Tracheal tug
CPR Guidelines1
Maneuver
Adult
Child
Infant
Adolescent and older
1 year old - adolescent
< 1 year old
Rescue Breathing without CPR
10-12 breaths/min
(~ 1 breath every 5-6sec)
12-20 breaths/min
(~ 1 breath every 3-5 sec)
12-20 breaths/min
(~1 breath every 3-5 sec)
Compression-ventilation ratio
30:2 for 2 rescuer
15:2 for 2 rescuer
15:2 for 2 rescuer
Compression landmark
Center of chest, between
nipples
Center of chest, between
nipples
Just below nipple line
Compression Method
2 hands
2 hands or 1 hand:
2 thumb with encircling hands
Compression Depth
1 ½-2”
1/3-1/2 depth of chest
1/3-12 depth of chest
Compression rate
100 /min
100/min
100/min
Airway/anatomy differences (adult pattern by ~8 years of age)
Obligate Nose breather (<6 months)
Poor tolerance to nasal obstruction
Large Tongue
-Neck extension may not relieve obstruction
-More difficult to get tongue out of visual field for intubation
Large head in proportion to body
-Anterior flexion due to large occiput,
-When supine may cause airway obstruction
Large U-shaped epiglottis
-More acute angle with vocal cords
-More susceptible to trauma
Larynx
More anterior and cephalad
Cricoid
-Narrowest part of airway
-↑ Raw with edema/infection
Trachea
-Small diameter, high compliance
-Collapses easily with neck hyperextension or hyperflexion
-↑ Raw with edema/infection
Alveoli
-↑ closing capacity
- No pores of Kohn= ↑air trapping and ↓ collateral ventilation
Chest Wall
-↑ A-P diameter, horizontal ribs, rely on RR to increase VE
-↑ compliance due to weak rib cage, FRC determined by elastic recoil of lungs
Respiratory Muscles
-Diaphragm is primary muscle used
-accessory muscles weak and ineffective