1. Age Suction PressureInstillation Suction Catheter (- mm Hg)Volume(ml) (F) < 1 yo60-800.5-1.02 x ETT ID 1-12 yo80-1200.5-3.0 >13 yo100-1500.5-5.0 *prn only* Intubation 1 Suction 2 Line up depth marking on suction catheter to depth marking on ETT. 4.0 ETT and smaller suction a minimum of Q8H Instillation volume is important to limit and document in infants and small children VAP protocols apply Resistance to passage of ETT:use ½ size smaller Cuff pressure to be kept < 20 cm H2O Leak at <10cm H2O: exchange ETT for ½ size larger Smaller ETT=  Raw ETT follows chin. Pt position for care and CXR ++ important. Chin low=ETT low Shorter trachea= greater chance for extubation if traction applied to ETT. Hold your tube with reference to pt with any pt movement, suctioning, manual ventilation or transport! Depth of ETT recorded ATN, ATT or ATG Smaller ETTs may slip through tube holders- consider taping ETT AgeETT IDETT DepthBladeStylet (mm) (cm ATG/ATT) (F) 3 X ETT * CXR to confirm <12 mo3.5-4.0 uncuffed10.5-12Miller 0-1 1 yo3.5 cuffed12-13.5Miller 1-26 2 yo4.0 cuffed13.5 4 yo4.5 cuffed15Miller 2 6 yo5.0 cuffed16.5Mac 2 8 yo6.0 cuffed18 10 yo6.5 cuffed19.5 14 12 yo7.0 cuffed21Mac 3 teen7.0-8.0 cuffed21 AgeRRTiVtPEEP (s)(ml) (cm H2O) < 1 yo250.35-0.55 4-6 ml/kg5 > 1 yo200.5-1.0 * Ventilation Initiation Guidelines Ideally want PIP <25 cm H2O With  RR may need to  Ti Consider Pressure ventilation to limit PIP Accept pH > 7.25 manipulate RR to achieve Accept PO2 > 60 When MAP >16-18 consider APRV/ HFOV Want 8-9 posterior ribs inflation on CXR Wean to minimum PS of 8 for infants, 6 for children *Admission weight (exceptions obese/ fluid overloaded) *If no tubing compensation will need to  Vt Problematic ETT Leak -Choose pressure mode of ventilation -Need to assess chest rise for adequate Vt -Measured Vt’s inaccurate -Pt position will affect leak -Can pack around ETT with NS soaked nasal packing as temporary fix if issues with CO2/O2. DO NOT CUT and tape to face. -Exchange ETT for larger size Should have leak around ETT prior to extubation IF NO LEAK with cuff deflated: Consider Dexamethasone pre-extubation Have epinephrine 1:1000 neb ready (0.5 ml/kg up to max of 5 ml) post-extubation Remember anything added to the circuit after the wye is DEADSPACE and may be more significant with smaller Vt.

2. AgeRRBP*HR awakeHR asleep <12 mo30-6087-105/53-66100-19075-160 1-3 years24-4095-105/53-6680-16060-90 3-5 years22-3495-110/56-7070-14060-90 6-12 years18-3097-112/57-7160-11060-90 13-18 years12-16112-128/66-8060-9050-90 *Lower limit of SBP =70 + (2 x age in years) Infants and small children don’t like strangers. RR, BP and HR will . Evaluate prior to entering room if possible Respiratory failure is 1° cause of cardiac collapse. Intervene early. Children have large compensation capacity. Must recognize shock early. Too late once decompensated. Normal Vital Signs 1 Airway/anatomy differences (adult pattern by ~8 years of age) Signs of  WOB ManeuverAdult Adolescent and older Child 1 year old - adolescent Infant < 1 year old Rescue Breathing without CPR10-12 breaths/min (~ 1 breath every 5-6sec) 12-20 breaths/min (~ 1 breath every 3-5 sec) 12-20 breaths/min (~1 breath every 3-5 sec) Compression-ventilation ratio30:2 for 2 rescuer15:2 for 2 rescuer Compression landmarkCenter of chest, between nipples Just below nipple line Compression Method2 hands2 hands or 1 hand:2 thumb with encircling hands Compression Depth1 ½-2”1/3-1/2 depth of chest1/3-12 depth of chest Compression rate100 /min ↑RR, Apnea Nasal flaring Head bobbing Seesaw respirations CPR Guidelines 1 Accessory muscle use grunting Obligate Nose breather (<6 months)Poor tolerance to nasal obstruction Large Tongue-Neck extension may not relieve obstruction -More difficult to get tongue out of visual field for intubation Large head in proportion to body-Anterior flexion due to large occiput, -When supine may cause airway obstruction Large U-shaped epiglottis-More acute angle with vocal cords -More susceptible to trauma LarynxMore anterior and cephalad Cricoid-Narrowest part of airway -↑ Raw with edema/infection Trachea-Small diameter, high compliance -Collapses easily with neck hyperextension or hyperflexion -↑ Raw with edema/infection Alveoli-↑ closing capacity - No pores of Kohn= ↑air trapping and ↓ collateral ventilation Chest Wall-↑ A-P diameter, horizontal ribs, rely on RR to increase VE -↑ compliance due to weak rib cage, FRC determined by elastic recoil of lungs Respiratory Muscles-Diaphragm is primary muscle used -accessory muscles weak and ineffective Chest retractions Tracheal tug