CHAPTER ■ AIRWAY JOSHUA NAGLER, AARON J DONOGHUE, LOREN G YAMAMOTO GOALS OF EMERGENCY THERAPY Tracheal intubation (TI) is a fundamental procedure during resuscitation of a critically ill child The goals of therapy are the placement of an artificial airway in the trachea in a safe, expedient fashion, while simultaneously avoiding physiologic deterioration (hypoxia, hypercapnia, bradycardia, hypotension) TI is indicated for any clinical state where existing or impending failure exists of oxygenation, ventilation, neuromuscular respiratory drive, or airway protective reflexes It may also be performed in critically ill patients in whom the projected clinical course is concerning, or for patients requiring transport who are at risk for deterioration Reports in pediatrics have shown that the most frequent indications for TI in children involve neurologic failure (traumatic brain injury, cardiac arrest, status epilepticus) as opposed to primary respiratory failure, with trauma accounting for more than half of all cases of pediatric TI in the emergency department (ED) TI should be considered the definitive method of managing existing or impending respiratory failure from any cause in the ED (see Chapter Cardiopulmonary Resuscitation ) Pediatric anatomy and physiology have direct influence on intubation technique, equipment selection, and prevalence of adverse physiologic events during TI Table 8.1 summarizes the anatomic and physiologic features in children that are important to consider when approaching TI in a child The summary effects of the various respiratory physiologic phenomena described above are a greater tendency for hypoxemia and arterial desaturation, which must be kept in mind during the preintubation and intubation phases of the procedure Quality and Safety Despite the fact that TI is a fundamental, essential skill for emergency providers, pediatric TI is an uncommon occurrence when measured at the level of an individual provider A survey of pediatric emergency department (PED) directors found that the annual incidence of TI in the PED ranged from 12 to 64 cases per year Sixty-two percent of those surveyed believed that their faculty did not encounter sufficient exposure to TI in their clinical duties to maintain competence at this essential procedure Additionally, the same survey found that there was a negligible difference in the median number of TI cases per faculty at the PEDs