Tracheal Intubation Technique

As previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults.[1–4,17–19,99,114,115] Because of the smaller dimensions of the pediatric airway there is increased risk of obstruction with trauma to the airway structures. A technique to be avoided is that in which the blade is advanced into the esophagus and then laryngeal visualization is achieved during withdrawal of the blade. This maneuver may result in laryngeal trauma when the tip of the blade scrapes the arytenoids and aryepiglottic folds. There are several approaches to exposing the glottis in infants with a Miller blade. One philosophy consists of advancing the laryngoscope blade under constant vision along the surface of the tongue, placing the tip of the blade directly in the vallecula and then using this location to pivot or rotate the blade to the right to sweep the tongue to the left and adequately lift the tongue to expose the glottic opening. This avoids trauma to the arytenoid cartilages. One can thus lift the base of the tongue, which in turn lifts the epiglottis, exposing the glottic opening. If this technique is unsuccessful, one may then directly lift the epiglottis with the tip of the blade (see Video Clip 12-1, Coming Soon). Another approach is to insert the Miller blade into the mouth at the right commissure over the lateral bicuspids/incisors (paraglossal approach). The blade is advanced down the right gutter of the mouth aiming the blade tip toward the midline while sweeping the tongue to the left. Once under the epiglottis, the epiglottis is lifted with the tip of the blade, thereby exposing the glottic aperture. By approaching the mouth over the bicuspids/incisors, dental damage is obviated. This is a particularly effective approach for the infant and child with a difficult airway. Whichever approach is used, care must be taken to avoid using the laryngoscope blade as a fulcrum through which pressure is applied to the teeth or alveolar ridge. If there is a substantive risk that pressure will be applied to the teeth, then a plastic tooth guard may be applied to cover the teeth at risk.