Which children require intubation

Which children require intubation? 

Although the most obvious indication for endotracheal intubation is sustained apnea, a number of other indications exist:

  • • Inadequate CNS control of ventilation
  • • Functional or anatomic airway obstruction
  • • Strong potential for developing airway obstruction (e.g., inhalation airway burns, expanding airway hematoma)
  • • Loss of protective airway reflexes
  • • Excessive work of breathing, which might lead to fatigue and respiratory insufficiency
  • • Need for high airway pressures to maintain effective alveolar gas exchange
  • • Need for mechanical ventilatory support
  • • Potential occurrence of any of the preceding during patient transport

In many instances, bag-mask ventilation and bag–endotracheal tube ventilation are equally effective for the patient. In such circumstances, it is logical to employ the method that the rescuer is best able to deliver. One prospective study randomized the use of bag-mask ventilation and endotracheal intubation by paramedics in 830 out-of-hospital pediatric arrests. There was no significant difference in survival (30% versus 26%, respectively) or good neurologic outcome (23% versus 20%) between the two groups of children. Subsequent studies confirmed that bag-mask ventilation is preferred in the field given the high incidence of intubation-related complications in patients managed by prehospital providers in the United States. In Europe, where physicians, and not paramedics, manage patients at the scene, intubation is strongly preferred and complications are minimal. 

Sources

DiRusso SM, Sullivan T, Risucci D, et al: Intubation of pediatric trauma patients in the field: Predictor of negative outcome despite risk stratification. J Trauma 2005;59:84-90. 

Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA 2000;283:783-790. 

Gerritse BM, Draaisma JM, Schalkwjk A, et al: Should EMS paramedics perform paediatric tracheal intubation in the field? Resuscitation 2008;79:225-229. 

Martinon C, Duracher C, Blanot S, et al: Paediatric prehospital tracheal intubation: What makes different our practice across the ocean? Resuscitation 2010;81(5):634.

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