Link To PedsCrit‘s “Intubation Essentials with Dr. Alyssa Stoner and Dr. Gina Patel, Part 2 Airway Equipment”

Today’s resource is outstanding for ALL LEARNERS who are taking the Pediatric Advanced Life Support course (PALS).

Today, I reviewed the podcast, linked to, and reviewed the show notes of PedsCrit‘s*
Intubation Essentials with Dr. Alyssa Stoner and Dr. Gina Patel, Part 2 Airway Equipment

*This PedsCrit link is to a complete list of all the topics covered on this wonderful site. At the time of this post, there are 78 pediatric critical care topics covered.

Here are the show notes from today’s resource.

Intubation Essentials– Part 2 Airway Equipment

About our guests:
Dr. Alyssa Stoner is an Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine and practicing pediatric intensivist at Children’s Mercy Kansas City.
Dr. Gina Patel is a fellow in pediatric critical care at Children’s Mercy Kansas City.

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  • The participant will be able to determine the appropriate size and depth of insertion of endotracheal tube based on patient’s age utilizing a common estimation formulas.
  • The participant will be able to describe the appropriate patient set up; including positioning for a successful intubation.

Transcript of the podcast*

*I prepared this podcast transcription with a dictation service and I proofed it. I am a primary care physician. The creators of the podcast had no involvement in or responsibility for the preparation of this transcript.

I will take this transcript down if requested by the PedsCrit authors.*

*Actually I will place it on a non-public post on the website so that it will be available for my use.

All that follows is from the transcript of PedsCrit‘s*
Intubation Essentials with Dr. Alyssa Stoner and Dr. Gina Patel, Part 2 Airway Equipment

Intubation Essentials with Dr (Completed 11/28/23) Part 2 Airway Equipment

Speaker 1 (00:00):

Intro snippet

Speaker 2 (00:11):

Hi everyone and welcome to the PedCrit podcast. My name is Zach Hodges and I’m a current PICU fellow at UT Southwestern in Dallas.

Speaker 3 (00:17):

And I’m Alice Shanklin. I’m a peds ICU fellow at Children’s National Hospital in Washington DC.

Speaker 2 (00:22):

Alice, will you remind our listeners what we do here at the Peds Crit podcast?

Speaker 3 (00:26):

Yes. So PedsCrit is a collaborative educational podcast. We are working with pediatric critical care educators, mostly across the United States, but also internationally to create high yield blog and podcast episodes on core PICU topics.

Speaker 2 (00:38):

And listeners, if you’re a pediatric critical care provider and would like to become involved in this project, be sure to reach out to us by email or on our

Speaker 3 (00:46):

Yes, we want to create a space in the online peds ICU community by collaborating with guest educators on their favorite critical care topics. Zach, who are we talking with today?

Speaker 2 (00:55):

So today we’re speaking with Gina Patel and Alyssa Stoner. So first, Dr. Stoner is an assistant professor of pediatrics at the University of Missouri Kansas City School of Medicine and is a pediatric intensivist at Children’s Mercy Kansas City.

Speaker 3 (01:09):

Yes. And Gina Patel is a second year peds critical care fellow at Children’s Mercy Hospital from Atlanta, originally. In these next few episodes we’re talking about the essentials of intubation in multiple parts

Speaker 2 (01:21):

And on today’s episode part two, we’re really focusing in on the equipment that you need for intubation.

Speaker 3 (01:26):

Yes, Zach? The thing that I love about this episode is they’re focused on cuffed tubes versus micro cuff tubes, but it’s essential to our practice regardless. Let’s get to the episode.

Speaker 1 (01:38):

So now that we have gone through the checklist, what I like to do is I like to approach how do we determine the equipment size, what’s the right equipment and what do you actually need from that? So most specifically, the endotracheal tube. And so at our institution we carry an endotracheal tube called the micro cuff endotracheal tube, and there’s some advantages and disadvantages to having the micro cuffed endotracheal tube. Gina, do you want to speak a little bit about this?

Speaker 4 (02:06):

Yes. So in my residency we didn’t have micro cuffed ET tube, so we definitely had to take that into account in terms of when we intubated doing the math age divided by four plus four versus three and a half. In our current institution at Children’s Mercy, we have micro cuff tubes. The micro cuff tubes, the cuff at the end of the ET t tube is thin enough that you don’t need to truly account for the half a centimeter or half a millimeter. I apologize. And what type of size ET tube that you need to utilize, and I don’t know if that’s the best way to explain it, Alyssa.

Speaker 1 (02:39):

Yeah, so when I think about the micro cuff endotracheal tube, it allows for us to get a little bit of a bigger size. And so when you think about the equation, instead of utilizing age divided by four plus four, you actually account for plus three and a half. And in addition, what I think is helpful from the micro cuff endotracheal tube is the cuff itself is oblong versus round. And so there disperses the pressure a little bit on a larger surface area. So the idea is that it’s going to cause less harm. Previously in the pediatric population, people would say, oh, we’re going to use an uncuffed endotracheal tube because we don’t want to harm their vocal cords. And part of that was because of where the cuff is actually located. So on a micro cuffed endotracheal tube, the cuff is actually more distal than on a standard endotracheal tube.


The standard endotracheal tube actually has a round ball that’s a little bit more proximal. It also has a Murphy eye on it. So if you did right main stem a patient, you still could provide ventilation to the left lung, whereas on the micro cuff endotracheal tube, the Murphy eye is now gone, but your endotracheal tube cuff is more distal, which allows it to be below the level of the vocal chords, but still above the level of the carina and not be right main stem [bronchus]. The disadvantage to not having the Murphy eye though is as if you right main stem, you no longer are going to provide ventilation to that left side of the lung, and so it can be a little bit more pronounced when you have an issue with right main stemming. And so even more importantly, is it for you to determine the appropriate depth of insertion. So Gina, what’s the equation for depth of insertion of the endotracheal tube?

Speaker 4 (04:24):

So you typically do three times the size of the ET tubes. If you’re using a four O ET tube, you multiply it by three, so that’s about 12 centimeters. So that’s how deep you should go in at the teeth or the lips or the gums, whatever landmark. And then there are three black lines at the distal end of the ET tube. It’s difficult to look at the glottic inlet and where your markers are on your numbers while you’re intubating. So I just push the three lines past the vocal chords and then kind of come up to see how deep I am and then I can kind of adjust based on the three times the ET tube size to ascertain my depth.

Speaker 1 (05:04):

So how those markers actually work, Gina is that thick marker that’s at the most distal aspect is supposed to be at the level of the glottic inlet. And then those three smaller hashes that are above it are supposed to be seen above the vocal cords. And if you insert it like that every time you come out, you’ll be at the right depth at the gums. And then when you evaluate it on chest x-ray, you should be at the level above the carina, but having your cuffed portion below the level of the glottis. And so that is specific to the micro cuffed endotracheal tubes and is a difference between the standard cuffed endotracheal tubes that might be at other institutions.

Speaker 2 (05:44):

We should at least take a moment to review. So micro cuff tube, the cuff is oblong, that’s designed to spread out the pressure over a longer portion of the airway, maybe to reduce airway trauma. And the downside is you lose that Murphy’s eye, which is like a hole in the distal tip of the endotracheal tube on the sidewall. That would give you some redundancy for being able to ventilate both sides of the chest. The advantages is you’re able to get a bigger tube into a smaller baby. Is there a particular size endotracheal tube that when you get a larger than this size you don’t use a micro cuffed anymore or is it all the way up?

Speaker 1 (06:19):

They have them available all the way up. So at our institution we have the micro cuffed tubes from the smallest size to the largest size. And that’s just standardly what we use when we have to use a regular cuffed endotracheal tube is typically when we’ve gone out of stock. So oftentimes the three and a half to four O cuffed tubes tend to be the most popular based on our patient size and age. And so there’s been a couple of instances in which they’ve been on backorder, particularly during the beginning of covid there was some issues with backordered related equipment types of things because of all the different processing and all the different issues that we were dealing with Covid. And so then we had to kind of transition back into our, oh, we’re going to use our standard cuff endotracheal tube. So it was really helpful to know what do you have available in your institution even at different times of the year because it may vary.

Speaker 3 (07:13):

Oh wow. It seems like it changes the acuity of right main stemming a kid pretty significantly.

Speaker 1 (07:19):

Most certainly. And certainly if you have a kid who is acutely ill and has pathology on their left side and you right main stem, they’re going to have more profound hypoxia than perhaps somebody who has healthy lungs. And I’ve seen kids get themselves into trouble with having a bradycardiac arrest in that type of situation. And so it’s really important to pay attention to and be cognizant of

Speaker 3 (07:42):

If they don’t have the reserve on that side.

Speaker 2 (07:46):

And one more question about choosing the right size tube. You’re saying with the micro cuff, we don’t have to consider that being a reason to go down to half size? Correct. That’s really neat.

Speaker 1 (07:58):

So once you kind of decide, okay, now I have the right size of endotracheal tube. So let’s go back to our case scenario. So we have what, a three month old patient who is RSV or [rinovirus bronchiolitis] and she’s six kilos. So based on that information, what size of tube would you guys choose?

Speaker 2 (08:14):

So what comes to mind for me is I think the age divide that by four and then I would add four to that. So maybe a four.

Speaker 1 (08:22):

Yeah. So I actually would go down to the three and a half size in this infant. So our three and a half micro cuff tubes are going to be adequate and we’ll provide enough space for you. The four might be a little bit generous. So if you have a large three month old probably would be okay. But if you have kind of a puny three month old, the three and a half is going to fit a little bit better. So then you have to decide what kind of blade am I going to use in order to get this tube into the airway? And so in that instance, what we consider is the different kinds of blade types we have available to us. And that again, is going to be specific to the institution. The most common blade types that we have are the Miller blade and the Mac blade.


And so this sounds kind of silly, but I remember this all the way back from medical school. How do you remember which one is which? I can’t remember all the equipment. And so the way that I was taught was for the Miller blades, just like in the name Ls are straight. So your Miller blade is actually a straight blade. So these blades tend to be straight and a little bit more narrow in their width. And then the Mac blades or the Macintosh, there’s a C in the name. And so this is a curved blade and that’s kind of how I’ve always remembered it. And then the other thing to know about the Mac blade is that it’s a little bit wider in the width. And so that comes into play when you’re thinking about limited real estate, particularly in these young infants because if you have that blade in their mouth and then you’re trying to get a suction catheter maybe in there and then [an ET] tube, you may just run out of room.


And so that plays into deciding what type of blade you might choose. And then the other blade that is available to us within our institution is called a wiss hipple blade. And the advantage of this particular blade is that it comes in a half size. So it comes in a size one and a half, and it’s almost like a combination of a Mac in a miller. So it’s a little bit wider than the Miller blade, but it tends to be straight similar to the Miller blade just with a little bit at the end where it’s and has kind of a distal light source. And so I really prefer that blade. And in fact, we just had an email sent around to all the faculty that said, if you’re interested in this blade, please let us know and tell us why, because they’re trying to phase them out of our institution. And I was like, please don’t lose these blades. This is my favorite one. And so it’s helpful to know what you have available to you. So Gina, what other things do you consider from a sizing standpoint for blade size and type?

Speaker 4 (10:54):

I think the biggest thing is once again, going back to anatomy and knowing what type of blade to use. If it’s an infant, you’re going to have more of a floppy epi glottis. So knowing that you’re going to have to use more of your straight blade or your Miller blade, even if you’re having to use a cmac using the Miller Blade attachment for that. And then if you have an older patient, like a teenager, really leaning towards the Mac blade is probably more appropriate for their anatomy. And then we talked about, I don’t know if Alyssa mentioned the D blade that’s been useful, especially I’ve seen it used in patients with a C collar to help open up the airway a little bit better. I don’t know if Alyssa has any experience with the D blade, but I’ve seen faculty use it for teenagers that [post-trauma] have a C collar still in place, and they found it useful as well, anticipating that they were going to have a difficult airway just with their C collar in place.


Even though I’m still fairly new into my training, I’m more of an old school person, so I am still getting used to using a cmac and a GlideScope. My comfort level is just using the old school Miller/Mac blade. So really understanding what kind of equipment you’re comfortable with and how that’s going to affect your technique because the CMAC definitely changes the view a little bit. And so my comfort level isn’t the best, and I’ve heard other people say the complete opposite. So really understanding and really just getting familiar with all the equipment and having the same comfort level with all the equipment is pretty important.

Speaker 2 (12:27):

So the Miller Blade has the two straight L’s in the name, so that’s your straight blade. It’s a little bit more narrow. It’s designed for the younger patients who have a pretty narrow mouth and a floppy epiglottis. The Macintosh on the other hand, maybe that C in the word Macintosh is a curved blade. It’s a little bit wider, and it’s designed for our children who are a little bit older who have maybe have a little bit wider mouth and a little bit more structure to their epiglottis. Does that sound about right?

Speaker 1 (12:51):

Yeah, that sounds perfect. One of the things that I might just also point out between the Miller and the Mac is the technique in which you utilize them. So from a Miller standpoint, the technical technique that is advised is to actually pick up the epiglottis. And so you actually get a direct visualization of the vocal chords, whereas the Macintosh blade is designed to sit in the vallecula

Speaker 2 (13:16):

, so between the base of the tongue and the epiglottis. And actually what you’re seeing is more of an indirect visualization of the glottic opening. However, I will tell you that if you get into a bind and you kind of drop the epiglottis or aren’t able to kind of pick it up, it’s okay for you to use the Miller similar to a Mac and stick it in the valleula to get the view that you may see. You may not get the best view in that particular situation, but it’s still kind of an acceptable approach.

Speaker 3 (13:50):

And that’s why it matters so much that the epiglottis is a little more flexible. And you’d prefer to hold it up directly?

Speaker 1 (13:56):

Correct. Oftentimes in pediatrics that epiglottis will kind of be floppy and fall down into your airway and you won’t be able to see those vocal cords.

Speaker 3 (14:04):

And then fair to say, for one year and under, we’re using the Miller, [and we use the Miller]from one to two years just for the [narrower] width, and then for two years and older, we’ll try for the Mac.

Speaker 1 (14:13):

Yeah. One of the strategies that I actually think about is weight. Kids who weigh greater than 20 kilos, I tend to switch over to a Mac two. So generally speaking for the infant population, I’ll use a Miller and as we get to the preschool age group, I’ll switch into that Wis-hipple 1.5, and then as we get to the 20 kilos and greater, I switch over to a Mac two. And as you get into that school age to adolescents, you get into the Mac three and depending on their body habitus can get all the way up to a Mac five. Really a Mac five is pretty large, and that’s probably going to be in your adolescent patient who’s obese, and it’s a pretty big blade, but it is helpful to have in those situations in which you have a large patient in oral pharynx that you need to deal with. Nice.

Speaker 2 (15:03):

I think we can remember that. So a Miller for one year and less, Macintosh after about 20 kilos, and then between one and two, either a Miller or Wis-hipple.

Speaker 1 (15:13):

Yeah. So that kind gets us through some of the equipment pieces. Gina has talked about this CMAC versus GlideScope. One might wonder what on earth are these things? You’re talking a foreign language to me, so I just wanted to clarify a little bit about what that might be. So when we’re referring to a cmac, it’s actually a piece of equipment. So instead of direct laryngoscopy, it’s a video laryngoscopy. And so this particular blade has a fiber optic camera at the end of the blade, so you can visualize the glottic opening more easily. And there’s a couple different setups that you can come across. So one of the setups is where the video camera is actually on the handle of the blade that you’re using, which is really nice because you will be able to still do direct laryngoscopy and then those in the room can kind of look at that camera behind your shoulder and see what you are seeing.


And so it’s really nice from a teaching tool standpoint, but the blade is a little bit more clunky. The handle is clunky, it’s a little bit more difficult to manipulate, and sometimes the light source can go out. And so just like Gina had mentioned, really understanding what those pieces of equipment are. And then the other setup that people sometimes will see is the actual blade being connected with a cord to a tower that can kind of be broadcasted to the whole room with kind of a video monitoring on it so they can see the airway and various strategies have been utilized, and you may find one strategy to be more challenging than another. So some people would prefer just having the camera on their blades so they can kind of have that direct visualization. It’s right in front of them and they’re not kind of looking up and over to the side. Other people tend to the video camera on the side because it’s actually a bigger picture. And so that can be helpful. Helpful. I just kind of wanted to sort those two pieces out for you. Do you guys have any questions about what those pieces of equipment are or why they would be helpful?

Speaker 2 (17:09):

So when I think of video laryngoscopy, I think of good for teaching, but also good for rescue if you’re unable to see directly. I know also some other providers, we’ll just go to video as their first attempt, whatever they’re most comfortable with. It seems that whether you have the monitor that’s actually on the blade per se or on the TV monitor will be specific to your institution.

Speaker 1 (17:31):

Yeah, that’s correct. I think one other advantage too, like you mentioned for rescuing is there is this option of the D blade that Gina has mentioned. And so that D blade is actually a hyperacute blade that’s meant for a very anterior airway and it is [a] shape as one of the blades available through the GlideScope. One of the disadvantages of it though is that your endotracheal tube has to have the exact configuration of that blade in order to get into the airway. And with our smaller endotracheal tubes, the stylet tends to be more floppy and can be easily manipulated as you’re entering the airway. And so if you’re going to use that hyperacute blade, using a stiffer stylet is really important. And that little piece sometimes gets forgotten and people are like, well, I hate using that because I can’t ever get the endotracheal tube in. And sometimes it’s just a function of the equipment.

Speaker 3 (18:24):

So your tube really needs to be in the crevice on the side there. Yes, it needs to fit and stay. Yeah. Do you guys ever record hit record on your trainees into basic?

Speaker 1 (18:35):

So we haven’t as of yet, but I had been working on a process of being able to do that because I think from a learning standpoint, it’s incredibly helpful from a debriefing standpoint to understand in the moment feedback of how you could change your technique to improve upon it. So I think it’s really interesting, and we just got a cmac within our institution over the last year and a half, and so our trainees have been getting used to it, and as educators we’re getting used to it, it’s been really interesting. I’ve now had a handful of experiences with the trainees utilizing it and being able to stand behind their shoulder or across from them in the room and watch what they’re seeing. And then when we get done with the intubation, then I can provide them with direct feedback of, oh, I realized that you didn’t have an amazing view of your vocal chords, but I’m really glad that you opted to put the endotracheal tube into the black bubbles because that was the right thing to do at that moment in time. Whereas if I didn’t see what they were seeing, I wouldn’t be able to provide that level of feedback to them.

Speaker 2 (19:41):

Yeah, I think that’s so interesting and will be so valuable for the next layer of critical care fellows like myself coming through.

Speaker 1 (19:48):

I think it’d be helpful too, if you go back kind of like a simulation scenario, you go back and you have to watch yourself perform. It’s always really embarrassing and you’re like, why did I do that? That was terrible. But I think you can learn so much from it, and I think it’ll be very beneficial in how you perfect your skills.

Speaker 3 (20:05):

Yeah, I was just telling Zach that one of my NICU attendings did that for me.

Speaker 4 (20:10):

I made the mistake of telling one of my faculty members that I am way more comfortable with doing direct laryngoscopy rather than using a video.


And he was like, oh, well, we’re just going to use video from now on. And I’m like, why did I tell you? But it’s going to be good because I need to get used to the equipment. He’s like, you probably shouldn’t have told me that. I won’t let you DL anymore.

Speaker 3 (20:29):

That is funny. I was going to ask about the fiber optic endoscope and how you sort of coordinate that for nasal intubations.

Speaker 1 (20:36):

Yeah, so that is a great tool in somebody’s hands who is adept at it. And so the great advantage to it is that if you have somebody who has a difficult airway, you can get a little bit straighter approach to the airway through a nasal approach. However, the skillset to utilize that is very difficult to learn. And so at our institution and where I trained, we actually were provided with the opportunity to learn how to do pulmonary bronchoscopies. And so I’m very familiar with using a flexible endoscope, but I would say that I still don’t have the level of skillset that it requires for me to get prepared to do a difficult intubation nasally with an endosco

Speaker 3 (21:17):

If I was going to ask somebody to do something though, I would reach out to our anesthesia colleagues because they’re just a little bit more accessible. They always have somebody who’s available out of the OR who can bring a scope to our unit and facilitate that because it does take some coordination. So you have to get the scope set up on the tower appropriately. You have to make sure that your endotracheal tube is loaded on there appropriately. And then you need to have all of the other components that we’ve talked about in the room. So your patient set up, you have all of your equipment, you have the people, you have an IV that’s working, you have monitors working, and so it takes a little bit more coordination, but it can be really helpful in those patients who have a difficult airway. It’s also used for patients who perhaps have the need or desire to have an airway that’s a little bit more stable.


So in an example of our institution, we had a kiddo who had a prolonged intubation course related to an underlying diagnosis of hypotonia that took a while to get the true diagnosis of. And he oftentimes would bite down on his endotracheal tube and then his endotracheal tube would have to get changed out. And so ultimately we switched him to a nasal intubation and he did so much better and was much more comfortable, and it ended up being one of our anesthesia colleagues who helped us facilitate that. And so super helpful, but needs to be in the right set of hands.

Speaker 2 (22:49):

So use this for those really high risk airways who you have the luxury of getting extra hands involved, extra equipment, and what else am I missing?

Speaker 1 (23:00):

I think time. I think the biggest thing is it’s going to take more time because right, you’re going to have to call people the bedside and you’re going to have to have the time to set up the equipment appropriately. Aside from that, I think you covered it all.

Speaker 2 (23:11):

Well, good.

Speaker 3 (23:16):

And thank you for listening to this episode of PedsCrit. Please remember that everything discussed is intended for informational and educational purposes only. It should not be used as a replacement for medical advice. The views expressed during this episode by hosts and our guests are also their own and do not reflect the official positions of their institutions. If you have any comments, suggestions, or feedback, you can email us at peds crit You can also check out peds for detailed show notes and visit at crit peds on Twitter and at peds crit on Instagram for real-time show updates. Thank you again for listening.


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