Endotracheal intubation (ETI) involves placing a flexible plastic tube (ETT) into a child’s windpipe, or trachea. The tube is inserted through the mouth or nose, bypassing the vocal cords to establish a secure connection to the lower airway. The primary function of ETI is to secure a patent airway, allowing for controlled delivery of oxygen and ventilation. This procedure is reserved for critically ill children when their natural ability to breathe or protect their airway is compromised and less invasive methods of respiratory support are failing.
Severe Breathing Impairment
The most frequent reason for considering ETI is severe respiratory failure, occurring when the lungs cannot perform adequate gas exchange. This failure is characterized by hypoxemia (low oxygen) and hypercapnia (excessive carbon dioxide buildup). Conditions like severe asthma exacerbations, extensive pneumonia, or acute respiratory distress syndrome can overwhelm the respiratory system, leading to this state.
The body may initially compensate by increasing the rate and effort of breathing, leading to visible signs like nasal flaring and chest wall retractions. This strenuous work eventually exhausts the respiratory muscles, leading to a precipitous decline. Once breathing slows and becomes shallow, indicating muscle fatigue, intubation is necessary to take over ventilation using a mechanical breathing machine. The ETT allows precise control over oxygen and pressure delivery, which is often impossible with non-invasive support.
Intubation is also considered when a child requires a prolonged period of mechanical ventilation to recover from a serious illness. Even if initial breathing support is successful, the long-term need for controlled breathing assistance makes the ETT a more secure and stable airway management device. This ensures the lungs can be supported through severe lung injury or muscle weakness while the underlying medical condition is treated.
Compromised Airway Protection
A distinct indication for ETI is the inability of a child to protect their own airway, even if their gas exchange function is temporarily adequate. Protection of the airway relies on neurological reflexes, such as coughing and swallowing, which prevent foreign material like stomach contents or secretions from entering the lungs. When these protective reflexes are absent or severely diminished, the airway is considered unsecured and intubation is required to prevent lung injury.
This loss of protection is often seen with significant altered mental status, such as a Glasgow Coma Score of eight or less, which can result from a severe head injury, drug overdose, or profound systemic infection. Intubation in these situations seals the trachea using an inflatable cuff, ensuring the airway remains patent and safe. The ETT bypasses the compromised upper airway and allows for suctioning of secretions, which further reduces the risk of aspiration.
Airway obstruction caused by swelling or structural issues also necessitates ETI to bypass the blockage. Conditions such as epiglottitis, severe croup, or massive swelling from burns or anaphylaxis can rapidly narrow the upper airway to a point of near-total closure. In these cases, intubation is performed to secure an airway below the level of the swelling before it becomes completely impassable, a time-sensitive intervention to prevent suffocation.
Definitive Airway During Resuscitation
Endotracheal intubation becomes necessary during acute, life-threatening emergencies, particularly in the context of cardiopulmonary resuscitation (CPR). While bag-mask ventilation is the initial method for providing oxygen during CPR, ETI is considered the definitive airway management technique. Securing the airway with an ETT during cardiac arrest allows for continuous ventilation without interrupting chest compressions, optimizing the delivery of oxygen to the brain and heart.
The placement of the ETT in this setting provides a reliable, direct conduit for ventilation, which is crucial when circulation is low or has stopped. Although studies have shown that intubation during pediatric in-hospital cardiac arrest is sometimes associated with lower survival rates, likely due to procedure-related interruptions or complications, it is still an accepted practice to secure the airway during prolonged resuscitation efforts. The ETT also permits the administration of certain emergency medications, such as epinephrine, directly into the lungs if intravenous access is unavailable during the crisis.