Endotracheal Intubation In Children Research Articles

Interventions designed using quality improvement methods reduce the incidence of serious airway events and airway cardiac arrests during pediatric anesthesia.

Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement (QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests. A quality improvement team consisting of members of the Department of Anesthesia was formed and QI data from previous years were analyzed. The QI team developed a Smart Aim, Key Driver Diagram, and specific Interventions that focused on the accessibility of emergency drugs, the use of nondepolarizing muscle relaxants for endotracheal intubation in children 2 years and younger, and the presence of anesthesia providers until emergence from anesthesia in high-risk patients. The percentage of cases where muscle relaxants were utilized in children 2 years and younger for endotracheal intubation and where atropine and succinylcholine were readily available increased at both our base and outpatient facilities. Over the 2.5-year study period, the incidence of serious airway events and airway cardiac arrests was reduced by 44% and 59%, respectively compared to the previous 2-year period. We utilized QI methodology to design and implement a project which led to greater standardization of clinical practice within a large pediatric anesthesia group. Based on an understanding of system issues impacting our clinical practice, we designed and tested interventions that led to a significant reduction in the incidence of serious airway events and airway cardiac arrests.

Evaluation of glottic view through Air‐Q Intubating Laryngeal Airway in the supine and lateral position and assessing it as a conduit for blind endotracheal intubation in children in the supine position

We assessed the feasibility of blind orotracheal intubation in children using the Air-QILA as a conduit in supine position and the glottic view grading by fiberoptic bronchoscope (FOB) through it both in supine and lateral positions. After ethical approval and consent, 60 children were enrolled in the study. In the operating room, after attaching standard monitors to all children, anesthesia was induced with sevoflurane (2-8%) in oxygen (100%). Once the children became sedated, an i.v. access was established and injection glycopyrrolate (10 μg · kg(-1)), fentanyl (2 μg · kg(-1)), and atracurium (0.5 mg · kg(-1)) were administered. After 3 min, the Air-QILA was placed in supine position and glottic view was assessed by using FOB, in supine and right lateral decubitus position. In all children, gradings of glottic view in two different positions were noted. After that all children were turned supine, and orotracheal intubation was done blindly through the Air-QILA. The success rate, insertion time of the Air-QILA, and endotracheal intubation were noted. The Air-QILA placement was successful in 57 children in first attempt and three children required second attempt. However, blind endotracheal intubations through the Air-QILA were successful in 38 children in first attempt and 12 children required second attempt. In the remaining 10 children, where blind endotracheal intubation through the Air-QILA remained unsuccessful, conventional laryngoscopy was performed. In supine and lateral positions, Grade 1 glottic view was seen in 41 and 38 of total 60 patients, respectively. Turning of all children from supine to lateral decubitus position resulted in the deterioration of grading of glottic view in eight children and improvement in two children (P = 0.001). The Air-QILA is an easy to place supraglottic airway device with excellent airway seal and low airway morbidity. It may be useful as a conduit for blind orotracheal intubation in supine position and can be used as an effective alternative to FOB in low resource settings.

Efficacy of laser acupuncture in attenuating hemodynamic response to orotracheal intubation and postoperative nausea and vomiting in children undergoing strabismus surgery

BackgroundLaser acupuncture may be offered to patients with needle phobia and children. This study aimed to investigate efficacy of the acupuncture point stimulation (Liv3 and P6) in preventing PONV and hemodynamic response to intubation in children.MethodsSixty children, ASA I or II aged 3–12 years, undergoing strabismus surgery were divided into 3 equal groups; 20 child each Group I (laser acupuncture group), Group II (ondansetron group) 0.15 mg/kg IV group and Group III (control group). Laser stimulation was performed bilaterally over 30 s, 15 min before induction of anesthesia and 15 min after arriving in the recovery room. Systolic, mean and diastolic BP and HR were measured in groups I and III before induction (times 1, 2), before intubation (time 3) and every minute after intubation for 5 min (times 4–8). 0–3 PONV scale was reported in all 3 groups I, II and III at 0–1 h, 1–6 h and 0–12 h postoperatively.ResultsMABP and HR were significantly less in the acupuncture group at T4, T5 (P values are < 0.05) as compared with the control group. Nausea, retching and vomiting in the control group were statistically significantly higher than both acupuncture and ondansetron groups at all intervals.ConclusionLaser stimulation of acupuncture points P6 and Liv3 decreases but does not prevent hemodynamic stress-response to endo-tracheal intubation in children, and effectively decreases postoperative nausea, retching, and vomiting in children undergoing strabismus surgery.

Utilidad de la ecografía comparada con la capnografía y la radiografía en la intubación traqueal

ObjectivesThe aim of this study was to assess the usefulness of bedside ultrasound compared to capnography and X-ray for endotracheal intubation in children and newborns. Materials and methodsHemodynamically stable children intubated in pedriatric and neonatal intensive care unit were included. Endotracheal tube insertion was checked after every intubation attempt by tracheal ultrasound and capnography simultaneously. The endotracheal tube insertion depth was then checked by assesment of lung sliding by thoracic ultrasound. Thereafter, Chest X-ray was performed and interpreted as usual. Time to perform each technique was recorded. ResultsThe study included 31 intubations in 26 patients (15 in PICU and 16 in NICU). There were no statistically significant differences between tracheal ultrasound and capnography or between thoracic ultrasound and x-ray in identifying the correct endotracheal intubation and assessment of endotracheal tube insertion depth, respectively. Sensibility and specificity of ultrasound compared to capnography was 92% and 100%, and 100% and 75% compared to X-ray. Ultrasound was significantly slower compared to capnography [12 (4-16) vs 6 (3-12) seconds; P<.001] and significantly quicker compared to X-ray [0.22 (0.17-0.40) vs. 20 (17-25) minutes, P<.001]. ConclusionsUltrasound appears to be as effective as capnography, although slower, for identifying endotracheal intubation. Ultrasound may be useful in clinical situations, such as cardiopulmonary resuscitation where capnography is less reliable. Ultrasound is as effective and quicker than X-ray for assessment of endotracheal tube insertion depth, and it may contribute to decrease the routine use of X-ray after tracheal intubation.

Comparison of heart rate variability response in children undergoing elective endotracheal intubation with and without neuromuscular blockade: a randomized controlled trial

The routine use of neuromuscular blocking drugs (NMBD) for endotracheal intubation in children is the subject of much controversy. The analysis of heart rate variability (HRV) can reveal information about the functional state of the autonomic nervous system (ANS). The purpose of this study was to determine if HRV elucidates differences in the sympathovagal balance of children undergoing elective endo-tracheal intubation with and without neuromuscular blockade (NMB). In this prospective study, 38 children (2-6 years) scheduled for adenotonsillectomy were randomized into two groups to receive fentanyl 2 μg·kg(-1) and propofol 4 mg·kg(-1) , with either mivacurium 0.25 mg·kg(-1) (NMB group) or saline solution (NoNMB group) for anesthesia induction. The same experienced, blinded anesthesiologist performed endotracheal intubation. Heart rate variability, RR intervals, ECG as well as an electroencephalogram were recorded with HRV and BIS XP monitors, respectively. Heart rate variability was analyzed in the frequency domain. There was no significant difference in HRV changes immediately after mivacurium administration compared with an administration of saline. The groups were comparable for the bispectral index value (NMB 35 [33-41] vs NoNMB 34 [32-42]) during endotracheal intubation. Changes in both the low-frequency power and the low-/high-frequency ratio immediately after endotracheal intubation compared with the unstimulated state before laryngoscopy were significantly higher without NMB (P = 0.015 and P = 0.006, respectively), whereas there was no significant difference with respect to the high-frequency power. The stress response during endotracheal intubation in pediatric patients represented by the frequency domain analysis of HRV was found to be higher without NMB. When mivacurium was added to a propofol-fentanyl induction regimen, the ANS alterations during endotracheal intubation decreased significantly.

Pediatric cuffed endotracheal tubes

Endotracheal intubation in children is usually performed utilizing uncuffed endotracheal tubes for conduct of anesthesia as well as for prolonged ventilation in critical care units. However, uncuffed tubes may require multiple changes to avoid excessive air leak, with subsequent environmental pollution making the technique uneconomical. In addition, monitoring of ventilatory parameters, exhaled volumes, and end-expiratory gases may be unreliable. All these problems can be avoided by use of cuffed endotracheal tubes. Besides, cuffed endotracheal tubes may be of advantage in special situations like laparoscopic surgery and in surgical conditions at risk of aspiration. Magnetic resonance imaging (MRI) scans in children have found the narrowest portion of larynx at rima glottides. Cuffed endotracheal tubes, therefore, will form a complete seal with low cuff pressure of <15 cm H2O without any increase in airway complications. Till recently, the use of cuffed endotracheal tubes was limited by variations in the tube design marketed by different manufacturers. The introduction of a new cuffed endotracheal tube in the market with improved tracheal sealing characteristics may encourage increased safe use of these tubes in clinical practice. A literature search using search words "cuffed endotracheal tube" and "children" from 1980 to January 2012 in PUBMED was conducted. Based on the search, the advantages and potential benefits of cuffed ETT are reviewed in this article.

The air‐Q® intubating laryngeal airway for endotracheal intubation in children with difficult airway: our experience

The air‐Q^® intubating laryngeal airway for endotracheal intubation in children with difficult airway: our experience

Surface Anesthetic Effect of Compound Lidocaine Cream in Children Undergoing Ptosis Operation and General Anesthesia

Objective: To observe the efficacy of lidocaine-prilocaine cream(EMLA) preventing complications of endotracheal intubation in children undergoing ptosis operation. Methods: Sixty children undergoing ptosis operation were randomized into three groups of control(group C), two surface anesthesia groups of L1 and L2with 20 cases each. SBP, DBP and HR before and each timing after intubation, at bandaging eyes and extubation, extubation time, occurrence of movement during surgery, degree of restlessness during extubation and the incidence of complications in 24 hours after extubation were recorded. Results: The values of SBP, DBP and HR were increased after intubation in each group. There is no difference between group C and surface anesthesia groups before and 2min,10min after intubation(P>0·05). But the variation of group C was distinctly higher compared with surface anesthesia groups 30min and 1hr after intubation and at bandaging eyes and extubation(P< 0·05). The surface anesthesia groups L1 and L2 is almost the same (P>0·05). Extubation time is also close between these three groups (P>0·05). Compared with groups of C, the scores of restlessness in groups of L1 and L2 were significantly lower (P< 0·05). The incidence of pharyngeal complication after extubation was higher in group C than group L1 and group L2(P< 0·05). Conclusion: Although surface anesthesia with EMLA can not efficiently inhibit cardiovascular effects resulting from endotracheal intubation, this method can relieve the stress reaction caused by tracheal catheter during moderate and long time surgery and also can significantly prevent the restlessness and incidence of complications after extubation.

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Improving patient safety: Can we avoid emergent endotracheal intubations in children?*

Improving patient safety: Can we avoid emergent endotracheal intubations in children?*

Comments on use of winged laryngoscope blade for endotracheal intubation in children with cleft lip

Pediatric AnesthesiaVolume 20, Issue 1 p. 110-111 Comments on use of winged laryngoscope blade for endotracheal intubation in children with cleft lip Fu S. Xue, Fu S. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorJian H. Liu, Jian H. Liu Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorYu J Yuan, Yu J Yuan Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this author Fu S. Xue, Fu S. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorJian H. Liu, Jian H. Liu Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorYu J Yuan, Yu J Yuan Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China (email: fruitxue@yahoo.com.cn)Search for more papers by this author First published: 27 December 2009 https://doi.org/10.1111/j.1460-9592.2009.03214.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume20, Issue1January 2010Pages 110-111 RelatedInformation

Emergent endotracheal intubations in children: Be careful if it is late when you intubate*

Emergent endotracheal intubations carry a high risk of morbidity and mortality in critically ill adults. Although children may be at higher risk during this procedure as a result of age-related differences in anatomy and physiology, this has not been previously examined. The purpose of this study was to delineate the risks of emergent endotracheal intubations in children. Retrospective cohort study. A 122-bed free-standing children's hospital. We conducted a retrospective review of all intubations occurring outside of the operating room setting between October 2005 and October 2007. Elective intubations were excluded. Intubations were classified as emergent after review of the child's vital signs, blood gas values, and written documentation by nurses, respiratory therapists, and physicians. Intubations occurring on weekends or between 5 pm and 8 am on weekdays were categorized as "off-hours." None. During the study period, 137 intubations were performed, 77 of which (56%) were emergent. Emergent endotracheal intubations were significantly more likely to occur off-hours (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) and to be associated with a complication (odds ratio, 3.0; 95% confidence interval, 1.4-6.1). Complications occurred in 41% of all intubations. The most common complications were desaturations (29% of all intubations), hypotension (16%), and bradycardia (7%). In a multivariate logistic regression analysis, emergent intubation, off-hours intubation, three or more attempts at intubation, smaller endotracheal tube size, and admission for cardiovascular disease all increased the likelihood of experiencing a complication during intubation. Complications were not associated with an indication for intubation or baseline chronic disease of the child and were not associated with prolonged intensive care unit course or duration of mechanical ventilation. Emergent endotracheal intubations are commonly performed in children, are two times more likely to occur off-hours, and are associated with three times the risk of complications as nonemergent intubations.

Use of an adult fiberoptic bronchoscope to facilitate endotracheal intubation in children with difficult airways

Pediatric AnesthesiaVolume 19, Issue 11 p. 1133-1135 Use of an adult fiberoptic bronchoscope to facilitate endotracheal intubation in children with difficult airways Fu S. Xue, Fu S. Xue Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorJian H. Liu, Jian H. Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorYan M. Zhang, Yan M. Zhang Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this author Fu S. Xue, Fu S. Xue Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorJian H. Liu, Jian H. Liu Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorYan M. Zhang, Yan M. Zhang Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this authorXu Liao, Xu Liao Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (email: [email protected])Search for more papers by this author First published: 04 October 2009 https://doi.org/10.1111/j.1460-9592.2009.03150.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume19, Issue11November 2009Pages 1133-1135 RelatedInformation

挿管後の小児の喉頭気管狭窄症例

挿管後の小児の喉頭気管狭窄症例

Facilitation of Endotracheal Intubation in Children with Topical Lidocaine during Sevoflurane Induction

Facilitation of Endotracheal Intubation in Children with Topical Lidocaine during Sevoflurane Induction

Pediatric Laryngoscope Blade Size Selection Using Facial Landmarks

The study evaluates whether facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children. We tested the hypothesis that the laryngoscope blade measuring 10 mm or less distal or proximal to the angle of the mandible (when the flat portion of the blade follows the facial contour from the upper incisor teeth to the angle of the mandible) will demonstrate greater success and ease of oral tracheal intubation. We performed an observational study that prospectively evaluated a convenience sample of children 8 years old or younger and who were undergoing direct laryngoscopy for oral endotracheal intubation in the operating room, outpatient surgery center, emergency department, or pediatric intensive care unit of a tertiary referral medical center. Ease and success of oral tracheal intubation were compared with distance measurements from the angle of the mandible to the tip of the laryngoscope blade. Blade lengths considered too short (blade lengths >10 mm proximal to the angle of the mandible) were more likely to be associated with more than 1 attempt at intubation. Only 57.1% (12/21; 95% confidence interval [CI], 36.5-75.5) of the intubations using the shorter blade were performed on the first attempt as compared with 89.7% (26/29; 95% CI, 73.6-96.4) of the intubations using the recommended length or 85.7% (6/7; 95% CI, 48.7-97.4) of the intubations using blades extending longer than 10 mm past the angle of the mandible. The distance from the upper incisor teeth to the angle of the jaw seems to be an excellent clinical landmark for laryngoscope blade length selection for pediatric intubations. When the blade (excluding the handle insertion block) is placed at the upper midline incisor teeth and the tip is located within 1 cm proximal or distal to the angle of the mandible, oral tracheal intubations are more consistently accomplished on the first attempt. Our observations suggest that facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children.

Comparison of the Effects of Propofol and Ketamine on Respiratory Mechanics during Anesthetic Induction in Children

Background: Propofol and ketamine are believed to reduce airway resistance. The aim of the present study was to compare the effect of propofol and ketamine on respiratory mechanics after endotracheal intubation in children. Methods: Forty pediatric patients were assigned randomly to two groups: propofol (n = 20) and ketamine (n = 20). Patients were anesthetized with propofol (2 mg/kg) or ketamine (2 mg/kg). All patients were paralyzed with rocuronium (0.8 mg/kg) and intubated and ventilated mechanically (: 30-40 mmHg, tidal volume: 10 ml/kg, respiratory rate: 15-25 time/min). Peak inspiratory pressure (PIP), respiratory resistance (Rr), dynamic compliance (Cdyn) and expiratory tidal volume (Vte) measurements were recorded at five time points; 0.5 min after intubation without sevoflurane (baseline), following 2.5 min, 5 min, 7.5 min and 10 min of ventilation with 2% sevoflurane- 50% nitrous oxide. Results: Rr at 0.5 min after intubation was 27.4 12.7 cm/L/s in the propofol group, and 30.0 13.5 cm/L/s in the ketamine group. Cdyn at 0.5 min after intubation was 28.0 9.9 ml/cm in the propofol group, and 25.1 10.6 ml/cm in the ketamine group. There was no significant difference in the response of PIP, Rr, Cdyn and Vte between two groups and within groups. Conclusions: We suggest that the effects of propofol and ketamine on respiratory mechanics were similar during anesthetic induction in children.

Pediatric Laryngoscope Blade Size Selection Using Facial Landmarks

Study Objectives: The study evaluates whether or not facial landmarks can be used to estimate the most appropriate laryngoscope blade length for oral endotracheal intubation in children. We tested the hypothesis that the laryngoscope blade measuring no more than 10 mm distal or proximal to the angle of the mandible (when the flat portion of the blade follows the facial contour from the upper incisor teeth to the angle of the mandible) will demonstrate greater success and ease of oral tracheal intubation.

Rabbit Model of Airway Stenosis Induced by Scraping of the Tracheal Mucosa

Prolonged endotracheal intubation in children often induces intractable airway stenosis. The aim of the present study was to establish a new model of airway stenosis for developing an effective method of treatment. The rabbit trachea was annularly incised, and the tracheal mucosa was scraped with a nylon brush. The trachea was then closed. Nine days after scraping, the trachea was microscopically examined. All of the examined rabbits showed tracheal stenosis, ranging from 22% to 82% in diameter and from 48% to 97% in cross-sectional area. The stenotic lesion was confined within the scraped region, not including the sutured region. Histologic examination showed inflammation in the stenotic lesion with submucosal hyperplasia caused by proliferation of fibroblasts and thickening of collagen fibers. This method can be easily carried out and assures induction of airway stenosis. This model may be useful for developing methods for treating airway stenosis in the early stage.

Prolonged Per-laryngeal Endotracheal Intubation in Children: 40 Years On

Because tracheostomy has a very high complication rate in small children, prolonged mechanical ventilation was not performed satisfactorily in infants until a technique was developed that allowed prolonged per-laryngeal endotracheal intubation in children. Plastic polyvinyl chloride endotracheal tubes were introduced in the 1950s; they soften at body temperature, and are much less likely to cause subglottic stenosis than endotracheal tubes made from metal or rubber. The first account of prolonged per-laryngeal intubation of infants using polyvinyl chloride tubes was written by Dr Bernard Brandstater, and this remarkable document is reproduced here. It sets out all the important principles of endotracheal intubation in children: the tube must fit easily through the cricoid ring, it must be firmly fixed in place with the tip in the mid trachea, meticulous humidification and suction are essential, and the tube should be changed only if there are signs of obstruction.