Question

Explain the differences between, and difficulties of, intubating special populations such as obstetric, bariatric, and paediatric patients.

Answer 1

Maternal anatomical and physiologic changes of pregnancy can contribute to airway-related adverse events, with advanced
maternal age and associated comorbidities further exacerbating the impact of these changes

Patient Positioning

Optimal patient positioning is essential prior to induction of GA in all patients but especially in pregnant patients. A 208 to 308 head-up position may facilitate insertion of the laryngoscope, improve the view of the glottis, increase functional residual capacity (FRC), and reduce the risk of gastric regurgitation. Aligning the external auditory meatus with the suprasternal notch may be superior to the typical ‘sniffing’ position and is particularly helpful in the obese patient. This ramped position can beachieved with the use of specific equipment ( or by pillows placed under the patient’s shoulders and head
Preoxygenation

Effective preoxygenation delays desaturation following induction of GA, especially in the pregnant patient with analready decreased FRC. Denitrogenation is best indicated by end-tidal oxygen fraction (FETO2), and ensuring an FETO2 of 0.9 prior to
induction is recommended.3 Fresh gas flows of more than 10 L/min and a tight-fitting face mask are required for effective preoxygenation. In an emergency situation, 3 to 4 maximal capacity breaths of 100% oxygen may be as effective as the more commonly adopted 3 minutes of normal tidal breathing.

Pediatrics

A. Pre-treatment evaluation:
Assess clinical necessity for intubation. If informed consent is indicated this
must be granted before sedation begins. A directed history and physical should
be performed that includes:
1. Relevant history of acute and chronic diseases
2. Clarification of code status
3. History of prior intubation
4. Physical ex am with attention to anatomical defects of the airway and
evidence of respiratory compromi

5. Current medications and allergies
6. Time of last oral intake
7. Assess airway using Mallampati classification, extent of mouth opening,
thyromental distance, palate width, and neck mobility
B. Set up:
Gather all necessary materials and notify Respiratory Therapist to set up
ventilator.
C. Patient preparation
1. Explain procedure to patient/caregivers and acquire consent unless
emergency
2. Assess for sufficient IV access and attachment appropriate cardiovascular
and respiratory monitoring equipment.
3. Position patient in sniffing position. Use blankets as ramps if patient
requires additional aligning of oral, pharyngeal, and laryngeal axes.
D. Performing the procedure:
1. Wash hands and don personal protective equipment
2. Check equipment and check endotracheal cuff for leaks if using cuffed tube
3. Insert stylet into endotracheal tube.
4. Attach blade to battery base and assess light function. Have backup blades
of different type and sizes available.
5. Preoxygenate with 100% O2 using ambubag or Jackson-Reese circuit for 3-
5 minutes to wash out residual nitrogen gas.
6. If necessary administer appropriate sedatives or opioids.
7. Have an assistant apply cricoid pressure.
8. Assess for ability to mask ventilate.
9. If appropriate administer appropriate neuromuscular blockade and assess for
clinical effect.
10. Grasp the laryngoscope in the left hand
11. Open the patients’ mouth with the cross finger technique
12. Slowly insert the blade into the right side of the patient’s mouth using it to
push the tongue to the left. Advance the blade inward and midline toward
the base of the tongue.
13. The tip of the curved blade should be placed in front of the epiglottis in the
valecula. The tip of the straight blade should be placed under the epiglottis.
Apply pressure caudally and upward with the handle at a 18. For cuffed tubes: Inflate the ETT cuff if large leak is noted – do not
overinflate
19. Attach end tidal CO2 monitor and Jackson-Reese circuit to the ETT and
give positive pressure breaths.
20. Assess for proper placement of ETT by end tidal CO2 waveform, fogging in
ETT, bilateral breath sounds, symmetric chest movement, and absence of
breath sounds over the epigastrum, as well as return to baseline vital signs.
21. If assessment indicates that the ETT is not placed in the trachea, deflate the
cuff and remove the ETT. Resume mask ventilation with 100% O2.
Consult with ICU fellow or anesthesia staff on strategy to reattempt
intubation.
22. If breath sounds are absent on the left, deflate the cuff and withdraw the
ETT 0.5-1 cm and evaluate for correct placement.
23. Secure the ETT with tape or appropriate device.
24. Attach the ETT to the mechanical ventilator.
F. Follow-up treatment
1. Order and review STAT portable CXR to evaluate the location of the tip of
the ETT.
2. Order and review arterial blood gas 30 minutes post intubati45 degree angle to
the bed.
14. Lift the handle until the vocal cords are visualized ensuring that the blade or
handle is not levered against the incisors.
15. Grasp the ETT tube with stylet inserted in the right hand.
16. Gently insert the ETT along the right side of the mouth under direct
visualization of the vocal cords until the cuff is no longer visible.
17. Firmly hold the ETT in place, withdraw the blade, remove the stylet,