Pediatrics Answers 433(PALS) recommendations regarding ETTs. Previously, uncuffed ETTs were
recommended for all patients under the age of 8 years. This was based on
the anatomical consideration that the narrowest part of the airway in chil-
dren is the subglottic area whereas in adults it is the glottis (larynx) itself.
Though this is true, it has become clear through further research that cuffed
tubes are preferable for providing a better seal without an increased risk for
endothelial damage from overinflation of the balloon and will provide bet-
ter ventilation in patients with poor lung compliance. With this complica-
tion in mind, it is important not to blow the balloon up to a pressure greater
than 20 cm H 2 O. There are two acceptable methods for choosing the appro-
priate ETT size. One relies on the length-based resuscitation tape that
should be available and utilized in the resuscitation of all small children.
The formula that has been endorsed by the American Heart Association for
calculation of the appropriate tube size for a cuffed tubeisETT size (mm
of internal diameter of tube) = (age in years/4) + 3.This calculation in
the above patient would yield a size of 4.0 mm for a cuffed tube.
To calculate the size of an uncuffed ETT, the calculation is as follows:
size (in mm) = (age in years/4) + 4.That would yield an ETT size of5.0 mm
for an uncuffed tube. This is not one of the choices. That leaves (a, c, d, and e)
as incorrect choices. Finally, it is worth mentioning the emphasis that PALS
has placed on tube placement confirmation. This must be done by a variety
of methods. Auscultation over the chest as well as the stomach, bilateral
chest wall rise, pulse oxygenation monitor, and perhaps most importantly,
end-tidal CO 2 monitoring for patients with a perfusing rhythm are all essen-
tial methods for confirming placement.
392.The answer is c.(Fleischer and Ludwig, pp 307-313.)Foreign body
ingestionand aspiration are common in this age group with peak occur-
rence between 6 months and 4 years.In this patient, the position of the
coin on the anterior-posterior chest film aids with the diagnosis. When the
coin is in the esophagus it is seen head-on in the AP projection.When it
is localized in the trachea it is seen in the sagittal plane because the carti-
laginous tracheal rings in children are incomplete and remain open posteri-
orly, causing the coin to sit sagittal or sideways. After assessing the patient’s
status (respiratory distress, inability to swallow, etc), it is important to assess
characteristics of the foreign body ingested. Ingested foreign bodies usually
get obstructed in three common locations: thoracic inlet (60%-80%), at
the gastroesophageal junction (10%-20%), and at the aortic arch (5%-
20%). A good way to remember this is by their level in the spine: C4-C6, T8,