Failing airway, failing oxygen — paediatric intubation

Structured clinical encounter — resuscitation leadership

This station tests whether the candidate leads a team to the right airway decision under time pressure, sizes the tube and blade correctly, performs the procedure, confirms placement, and prevents the complications. Marks reward the explicit indication, the correct formula-based sizing, the capnography confirmation, and the safety net. [9] [11]

Stem

A four-year-old is brought to the emergency department with a 12-hour history of fever, stridor and worsening work of breathing. He is drooling, sitting forward, retracting hard, and now only rousable. Oxygen saturation is 88 per cent and falling despite high-flow oxygen. Heart rate 150, respiratory rate 40. The team looks to you. [9]

Candidate tasks

1. Lead the airway decision (2 minutes). State the indication aloud: a failing airway with impending loss of protection (drooling, drowsy, falling oxygenation). Intubate now, before the arrest. Assemble the team and name the roles. [9] [11]
2. Size the tube and blade (2 minutes). Uncuffed 5.0 mm, cuffed 4.5 mm; depth at the lips 14 cm (age over 2 plus 12, or three times the internal diameter). Curved Macintosh size 2 blade. Have a tube half a size up and down ready. [1] [11]
3. Perform or direct rapid sequence intubation (4 minutes). Preoxygenase with 100 per cent oxygen. Give a sedative (etomidate 0.3 mg per kg or ketamine 1 to 2 mg per kg) then rocuronium 1 mg per kg. Insert the blade, lift (do not lever), visualise the cords, pass the tube, withdraw the stylet. [7]
4. Confirm placement (2 minutes). Waveform capnography is the standard — a square-wave carbon dioxide trace over six breaths, with chest rise and equal air entry. Do not accept chest rise alone. Inflate the cuff only to a seal if a cuffed tube is used. [5] [11]
5. Prevent complications and plan (2 minutes). State the complications — hypoxia from prolonged attempts, oesophageal intubation, right main bronchus intubation, bradycardia, post-extubation stridor. Confirm tube depth on a chest radiograph, secure the tube, and document the airway plan before any transfer. [5] [9]

Examiners' discussion points

• Why intubate now and not watch? The child is tiring with a falling conscious state and oxygenation; he is losing the airway. A tube placed in calm conditions before the arrest is far safer than one placed in a chaotic arrest. [9]
• Defend the tube formula. Uncuffed is age over 4 plus 4; cuffed is age over 4 plus 3.5; depth at the lips is age over 2 plus 12. Cuffed tubes are now acceptable at all ages when sized correctly and the cuff pressure is kept below 25 cm of water. [1]
• The first look gives a poor view. Do not keep repeating direct laryngoscopy. Reposition, apply external laryngeal manipulation (BURP), and if still poor, switch to video laryngoscopy with a supraglottic airway ready. The evidence supports video laryngoscopy first-line for the difficult airway. [3] [9]
• Why rocuronium and not succinylcholine? Rocuronium 1 mg per kg gives comparable intubating conditions and avoids the succinylcholine contraindications (hyperkalaemia, burns, muscle disease, malignant hyperthermia). [7]

Marking grid (out of 20)