Nasotracheal intubation — preferable when an oral tube would interfere
with an intraoral surgical procedure — is safe in children of all ages and
isn't technically different than that for adults, with one exception. The
angling of the child's oropharynx usually requires a Magill forceps to feed
the tracheal tube in an anterior direction toward the glottic inlet. Use a
half-size smaller tube than you'd use for the oral route. Decrease bleeding
in the nasal passages by pre-soaking the tube in hot water to soften it. I
also administer a few drops of 0.05% oxymetazoline into each nasal pas-
sage.
If these basic maneuvers fail, and the oxyhemoglobin saturation is still
decreasing, the situation becomes dire and 1 of 3 possible actions is
appropriate:
• Insert an LMA. Appropriately sized LMAs should be immediately
available in every anesthetizing location. The LMA will establish ade-
quate ventilation unless it's wrongly positioned (which is more com-
mon with children) or the obstruction is caused by laryngospasm. So
you need to be very confident that the obstruction isn't being caused
by laryngospasm.
• Tracheal intubation. But only by adept practitioners and only if there's
some doubt about the cause of the obstruction. If laryngospasm has
occurred, it's usually possible to introduce a styletted endotracheal
tube through the glottic opening.
• Administer succinylcholine. Since laryngospasm is a common cause of
unrelenting upper airway obstruction in children, this may be needed
if conventional methods fail to reverse hypoxemia.
In the rare instance that none of these measures succeed, and the
child is becoming dangerously hypoxic, perform desperate last-
chance measures immediately:
• Reposition the patient. If an anterior mediastinal mass is suspected
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