Oral Approach

Oral Approach

1. Older children are placed in the “sniffing” position using a blanket. Infants and small children have large occiputs, and a small rolled towel placed under the scapulae can be helpful.
2. During laryngoscopy, the tip of the blade is used to elevate the epiglottis. If this technique does not provide a good view of the glottis, the laryngoscope blade can be placed in the vallecula even with a straight blade.
3. The distance from the glottis to the carina is about 4 cm in a term neonate. Pediatric endotracheal tubes have a single black line located 2 cm from the tip and a double black line at 3 cm; these markings should be observed while the tube is passed beyond the vocal cords.
4. If resistance is met during intubation, a half-size smaller tube should be tried.
5. After intubation, the chest should be examined for bilateral equal expansion, end tidal CO₂, and the lungs auscultated for equal breath sounds. There should be a leak around an uncuffed tube when 15 to 20 cm H₂O positive pressure is applied. If the leak is present at less than 10 cm H₂O pressure, the endotracheal tube should be exchanged for the next larger size.
6. The chest should be auscultated after every change in head or body position to verify equal bilateral breath sounds. Extension of the head can result in extubation, while flexion can result in tube advancement into either mainstem bronchus.
7. Endotracheal tubes should be securely taped and the numerical marking on the tube closest to the gingiva noted; migration of the endotracheal tube will be apparent from any change in this relation.