Endotracheal Tube (ETT) Sizes, Proper Placement, and Useful Airway Management Methods for the Pediatric Population in Children (Age 1 Year to Puberty or About 8 Years Old), Infants (12 Months of Age or Younger), and Neonates (28 Days or Younger)

The Primary Assessment after the Initial Impression of the advanced healthcare provider, begins with Airway (A) and Breathing (B) and exceptionally should be simultaneous with the evaluation of the patient’s status in Circulation/Hemodynamics (C), Disability/Differential Diagnosis (D), and Exposure (E) in combination with the Secondary Assessment, a targeted Physical Examination, and Diagnostic Imaging and Laboratory Studies during pediatric advanced life support, where airway management stabilization strategies must be implemented promptly and precisely as indicated. Understanding competently the endotracheal tube size, correct placement using feedback devices such as the end-tidal carbon dioxide (CO2) detectors and waveform capnography are only one of many keys to airway management stabilization in the Pediatric Population.

As an example, estimating endotracheal tube (ETT) size selection by the pediatric advanced healthcare provider for children aged 1 years old to puberty (with some end-point at 8 years of age or some at 10 years of age but before any signs of puberty as in breast development and menstruation in female teenagers and underarm air in male adolescents) – per the guidelines and recommendations of the American Critical-Care Nurses (ACCN) and the American Heart Association (AHA) in Palm Desert Resuscitation Education’s advance course for healthcare providers in Pediatric Advanced Life Support (PALS), Pediatric Emergency Advanced Assessment, Recognition and Stabilization (PEARS), and Airway Management – is usually based on the child’s age and uses the internal diameter [i.d.] in mm, whether that is a uncuffed or cuffed endotracheal tube (ETT) size:

• Uncuffed endotracheal tube (ETT) size (mm i.d.) = (Age in Years/4) + 4
• Cuffed endotracheal tube (ETT) size (mm. i.d.) = (Age in Years/4) + 3.5
  • Typically the cuff’s inflation pressure should be <20 to 25 cm H2O

Typically, the pediatric advanced healthcare provider’s baseline scope of practice and clinical experiences along with the use of evidenced-based guidelines in endotracheal tube (ETT) size measurements and correct placements through continued medical education in advanced clinical certification courses as well as through competency in peer reviewed medical and organizational-based journals such as in “Annals of Emergency Medicine,” “Anesthesiology,” “A Practice of Anesthesia for Infants and Children,” and “Pediatrics,” for instance, will provide the preeminent clinical pearls, assessment, and judgment in the best endotracheal tube (ETT) size to utilize during pediatric advanced life support, anesthesia induction for surgery, or any setting requiring emergency and sub-acute/non-acute airway management stabilization for the pediatric patient.

Moreover, pediatric advanced healthcare providers – like emergency department (ED) physicians, critical care unit (CCU) and intensive care unit (ICU) intensives, anesthesiologists, certified respiratory registered nurses (CRNAs), some surgeons, and other acute care doctors, for example – may elect to use the Vital Signs, Inc.’s Broselow Pediatric Emergency Tape, which is preferably and simply positioned in the bedside or unit “Crash Cart.” The color-coded length-based (not weight-based and, therefore, it is wise to incorporate the pediatric patient’s weight and body mass index, BMI) tape is an informational sheet provides recommendations for pediatric airway management including equipment guidelines and sizes in bag-valve masks (BVMs) for positive pressure ventilation (PPV); basic airway adjuncts use and measurements with oropharyngeal (OPA) and hyponasal/nasopharyngeal cannula (NPA) airways; oxygen (O2) masks suggestions such as pediatric non-rebreathers; end-tidal CO2 detectors; stylets; laryngoscopes; suction catheters; cuffed and uncuffed ETT sizes; ETT insertion lengths; rapid sequence pre-medications with induction agents, paralytic agents, and maintenance. It also provides fluid resuscitation and ins & outs (Is/Os) equipment sizes and pharmacological recommendations in compensated, hypotensive, and decompensated shock cases – blood pressure (BP) cuffs; vascular intravenous (IV) access gauge needles; and intraosseous (IO) access gauge needles; urinary Foley catheters; and nasogastric (NG) tubes. In addition, obstructive shock cases in tension and non-tension pneumothorax recommendations and equipment support in choosing thoracotomy needle gauges and chest tube sizes are detailed. There are also specific pharmacologic treatments and antidotes for seizures, overdose, and increased intracranial pressures (ICP) among other clinical emergencies that can cause pediatric hemodynamic instability, eventual clinical deterioration, and leading to “circling down drain” that requires cardiopulmonary resuscitation (CPR) and advanced life support (ALS).

During Palm Desert Resuscitation Education’s Neonatal Resuscitation Program (NRP), and Sugar, Temperature, Airway, Blood Pressure, Lab Work, and Emotional Support (S.T.A.B.L.E.) Program, pediatric advanced healthcare providers treating and managing infants and neonates will be provided appropriate education and training, in an ideal setting, in the selection of ETT sizes, proper placements, and other useful airway management methods for the Pediatric Population. For infants up to 1 year of age, an uncuffed ETT with an internal diameter of 3.5 mm is used. Preferably, for infants more than 3.5 kg and less than 1 year of age, a cuffed ETT with an internal diameter of 3.0 mm is used. Moreover, for infants and neonates needing an indication for an ETT advanced airway other than supraglottic advanced airways (e.g., laryngeal mask airways, LMAs, in cases when ETT insertion is not indicated), for moderate to severe apnea and respiratory arrest/failure to prevent further decompensation and possible cardiac arrest, the neonatal advanced healthcare provider should wisely turn to their case-hardened clinical experiences, base-line scope of practice, expert consultation, and strict evidenced-based reference recommendations, such as those pediatric and neonatal airway management guidelines stated in the new 6th S.T.A.B.L.E. Program Learner/Provider Textbook Manual.

More interestingly, for neonatal and infant advanced healthcare providers – such as neonatologists, neonatal nurse practitioners (NNPs), pediatric hospitalists, and respiratory care practitioners (RCPs), for instance – requiring quick advanced airway parameters for acute neonatal emergencies in airway management, some may turn to measuring the fifth finger width and fifth finger diameter to predict proper ETT size in most children in general. However, a more accurate estimation can be made using the age-based formula, but when the child’s age is unknown or when calculation is awkward or impossible, an accurate estimate can be made using the width of the fifth fingernail per studies with a comparison of methods in endotracheal tube selection in children. In addition, the correct endotracheal tube (ETT) size and length of insertion (tip to lip distance) can be estimated from the infant’s weight but usually some neonatal and infant advanced healthcare providers turn to the insertion depth (in centimeters, cm) that is equal to 6 + weight (in kilograms, kg). Some may also elect not to use a stylet in preemies and small for gestational age (SGA) neonates to prevent any pneumothoraxes that may occur from more invasive airway management procedures. Others anecdotally may also want to use their own digits as an alternative to utilizing the laryngoscope blade such as Miller 0 or Miller 1 while inserting the ETT in neonates and infants.

For more information and education in endotracheal tube (ETT) sizes, proper placement, and other useful airway management methods for the Pediatric Population in children (age 1 year to puberty or about 8 years old), infants (12 months of age or younger), and neonates (28 days or younger), please sign up for Palm Desert Resuscitation Education’s Pediatric Advanced Life Support, Pediatric Emergency Advanced Assessment, Recognition and Stabilization (PEARS), Airway Management, Neonatal Resuscitation Program (NRP), and Sugar, Temperature, Airway, Blood Pressure, Lab Work, and Emotional Support (S.T.A.B.L.E.) Program.

References

1. Endotracheal tube selection in children: a comparison of four methods
2. Endotracheal tube size for children (Age 1 to 8 years)
3. Technique for Insertion of an Endotracheal (ET) Tube

Other Scholarly References

1. King BR, Baker MD, Braitman LE, et. al. Endotracheal tube selection in children: a comparison of four methods. Ann Emerg Med. 1993 Mar;22(3):530-4. PMID: 8442540
2. Khine HH, Corddry DH, Kettrick RG, et. al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997 Mar;86(3):627-31; discussion 27A. PMID: 9066329
3. Wheeler, M, Cote, CJ, Todres, ID. The pediatric airway. In: Cote C, Lerman J, Todres ID (Eds). A Practice of Anesthesia for Infants and Children, 4th ed. Saunders-Elsevier, Philadelphia 2009. p.237. NLMN: 101482651
4. Kleinman ME, de Caen AR, Chameides L, et.al. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics. 2010 Nov;126(5):e1261-318. PMID: 20956433

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