INTUBATION SIMULATION  Fentanyl or Morphine — opioid (1-2 mcg/kg)

Induction agents/ Anesthetic drugs

 Ketamine: 1–1.5 mg/kg IV (maintains BP, good for asthma)
 Etomidate: 0.2-0.6 mg/kg IV
1. Assess the Airway (Use the LEMON criteria)
 Propofol: 1–2.5 mg/kg IV (may cause hypotension)
 Look externally for facial trauma, large tongue, beard, etc.
 Evaluate 3-3-2 rule: Paralytics/ Muscle relaxant
 Succinylcholine: 1–1.5 mg/kg IV
o Mouth opening ≥ 3 fingers
 Atracurium: 0.4-0.5 mg/kg IV
o Mentum to hyoid ≥ 3 fingers
o Hyoid to thyroid notch ≥ 2 fingers Induction agents
 Mallampati Score: Grade 1–4  Ketamine: 1 mg/kg IV (maintains BP, good for asthma)
 Obstruction: Any signs of swelling, infection, trauma?  Etomidate: 0.3 mg/kg IV (less commonly used in infants)
 Neck mobility: Flexion and extension capability  Propofol: 1–2 mg/kg IV (may cause hypotension)
 ✅ This anticipates difficult airways and prepares for backup Paralytics/ Muscle Relaxant
options if necessary.  Succinylcholine: 1–2 mg/kg IV
 Pediatric airways are smaller, more anterior, and easily  Rocuronium: 1.2 mg/kg IV
compromised.
 Medications provide optimal intubating conditions, reduce injury
2. Prepare Equipment (Mnemonic: SOAP ME) and resistance.
Item Checklist  In emergencies or neonates, may perform no-drug or sedated-only
Suction Yankauer tip, functional intubation.
Oxygen Bag-valve mask (BVM), NRB mask
Airway tools Laryngoscope (check light), ET tubes (check cuff), stylet, 5. Have patient on SNIFFING position
oral airway  Flexion at the level of the neck and extension at the level of
Pharmaceuticals Induction & paralytics (Etomidate, Succinylcholine) atlanto-occipital alignment (align external auditory meatus with
Monitors Pulse oximetry, BP, ECG sternal notch)
End-tidal CO₂ Capnography (colorimetric or waveform)  Elevate head 20°–30° if needed (especially in obese patients)
 ✅ Prevents failure due to missing or malfunctioning equipment.  ✅ Proper positioning improves glottic visualization and ease of
intubation.
 Laryngoscope  In Pediatrics patients, use a shoulder roll to elevate the chest and
Blade sizes: keep the head neutral. Sniffing position isn’t appropriate for
 size 3-4 in adults (male: 4, female: 3) infants — neutral alignment is ideal.”
 Endotracheal Tube (ETT):  Pediatric occiput is large— improper positioning can flex the neck
Optimal depth formula: and block the airway.
 Height of px in cm/7) - 2.5
Estimate:
 23 cm in males
 21 cm in females
Optimal distance from carina: 4 cm

 Pediatric Laryngoscope:
Blade type:
 Miller (straight) for neonates/infants
 Macintosh (curved) for older children
Blade sizes:
 Size 0: Preterm
 Size 1: Neonate
 Size 2: Infant–toddler
 Size 3: School-aged
 Endotracheal Tube (ETT):
Cuffed or uncuffed (Cuffed tubes are now accepted in most children >3 kg
with proper cuff pressure monitoring)
Size formula:
 Cuffed: (Age ÷ 4) + 3.5
 Uncuffed: (Age ÷ 4) + 4 6. Perform Intubation
 ETT insertion depth:  Laryngoscope on the left hand
Depth Formula:  Open the mouth with right hand (“scissor” technique)
 (ETT size × 3) or (Age ÷ 2) + 12  Insert blade into right side of mouth, sweeping tongue to the left
o Miller: Lift epiglottis directly
3. Pre-oxygenate (3–5 mins) o Macintosh: Place tip in vallecula, lift indirectly
 100% O₂ via NRB mask or BVM with reservoir  Advance blade until epiglottis is visualized
 Ensure good seal and chest rise  Lift up and away at 45° angle—do not lever on the teeth
 ✅ This builds oxygen reserve, reducing hypoxia risk during apnea  Then, visualize vocal cords
 Children desaturate rapidly due to high metabolic rate and low O₂  ✅ Technique ensures visualization of cords without causing trauma.
reserve.
7. Inserting Endotracheal Tube (ETT)
4. Administer Sedative/ Paralytics  Use right hand to insert ETT through cords
 Sedative/induction (Etomidate, Propofol, Ketamine)  Typical depth at teeth/gums: 21 cm (women), 23 cm (men)
 Paralytic (Succinylcholine or Rocuronium) 12-16 cm depending on age  (Age ÷ 2) + 12 (Pedia)
 Time onset of drugs (45–60 sec)  Remove stylet carefully while stabilizing the tube
 ✅ Sedation and paralysis optimize intubation condition and reduce  Inflate cuff with air (check for leak)
the gag reflex.  ✅ Tube placement within the trachea ensures airway control; cuff
inflation seals the airway.
Sedative
8. Confirm Placement
 Attach Bag-Valve-Mask and give 5 breaths
 Look chest rise, auscultate for bilateral breath sounds and absence
of epigastric sounds or gurgling
 Use capnography (gold standard): look for sustained waveform
 Check SpO₂ levels
 ✅ Confirmation avoids complications from esophageal intubation

9. Secure the Tube

 Note depth at lips/teeth
 Use commercial ETT holder or tape
 Reassess tube placement after securing
 ✅ Prevents accidental extubation or migration of the tube

10. Post-Intubation Management

 Chest X-ray to confirm placement
 Adult: 3–5 cm above carina
 Pedia: 1-2 cm above carina
 Continue sedation/paralysis if needed
 Set up ventilator or continue bagging
 Document: date, time, drugs, ETT size/depth, confirmation method

🧠 ADDITIONAL TIPS
 Always have backup airways ready: LMA, video laryngoscope,
cricothyrotomy kit
 In difficult airways, consider video laryngoscopy
 Avoid repeated attempts (>2): call for help early
 In cardiac arrest: prioritize minimal interruption of compressions

⚠️Common Pitfalls to Avoid:

 Using wrong ETT size (too small = air leak, too big = trauma)
 Inadequate oxygenation before attempt
 Delayed or missed esophageal intubation
 Overinflated cuff
 Poor ETT securing (high dislodgement risk in kids)