About Christine Whitten

I’ve been a practicing anesthesiologist for over 30 years. I am the author of the book Anyone Can Intubate, A Step-By-Step Guide to Intubation and Airway Management, now in 5th edition and eBook version with video. My book, as well as my training videos on intubation and airway management, are used in training programs both nationally and internationally.

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary.

Children are not miniature adults: in many ways normal pediatric anatomy and physiology make children more vulnerable to hypoxia, respiratory distress, and respiratory failure. Compared to adults, the leading cause of preventable death in pediatric emergencies – both medical and trauma – is failure to adequately manage the airway. Pediatric respiratory events carry a higher mortality than adult events (1).

I had my first introduction to just how different children are as a senior medical student on the anesthesia service — an elective that eventually proved life changing. My teacher had asked me what I wanted to do on the rotation and I had requested to take care of children. That resulted in a long pause in the conversation and a non-committal comment that we would just have see to how that went as the rotation progressed. Finally, on my last day my teacher assigned me to a room full of pediatric patients having either ear tube placement or tonsillectomies. Every child was a different age and every child seemed to have different anatomy. My teacher spent the day showing me how to adjust my newly acquired skills to each child. I left that rotation which deeper respect for the subtleties of pediatric airway management.

There is good reason why most providers are more nervous taking care of children, especially young children less than 2 years of age. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously changing. Managing the airway of a premature infant requires a slightly different technique than managing the airway of an older infant, a toddler, a child and a teenager. Not big differences, but enough to make care of the pediatric airway more challenging, especially for providers who care for children infrequently.

Fortunately, most children have easily managed airways. If you understand the differences, taking care of the typical pediatric airway is not difficult.

It’s a common trend to concentrate care of children in the hands of those who are more experienced. For example, anesthesia in young children is more frequently being done by pediatric anesthesiologists in children’s hospitals. While good in many ways, this trend deprives other providers of caring for children — making them less prepared for when they do have to care for a small child.

For those of you who rarely care for pediatric emergencies this book will teach you the anatomy, physiology and technical differences in recognizing respiratory distress, opening an airway, ventilating, and intubating infants and children. For those of you who routinely care for children, this book will share some of the tips and tricks I’ve learned for managing more challenging airways from 4 decades of practicing anesthesia.

Even if you don’t perform intubation yourself, chances are you will be assisting someone who does. Understanding how the techniques are performed will allow you to more effectively assist and improves the chance for a good outcome. Dosages, advantages and disadvantages of the different drugs for rapid sequence induction are also covered.

This book gives you step by step instructions on basic airway management guided by 267 illustrations and photos, plus over an hour of on-line video clips. These free video clips provide hours of footage of actual patients undergoing real surgical procedures, manikin demonstrations, and animations. The URL to my video page, which you’re welcome to use, is here.

The goal of Pediatric Airway Management is to give you a visual picture of airway management and intubation for each age of childhood. As you proceed through the book, use the video clips to picture yourself performing the steps. I hope my efforts make you confident in your ability to help children breathe. Anyone can learn how to to open an airway and ventilate a child.

My sincere wish is that this new book helps in the care of our littlest patients, no matter where they are.

May The Force Be With You!

Christine E. Whitten MD








When I was training, we used nitrous oxide on just about every anesthetic. It was easy to use. It was inexpensive. It didn’t tend to effect hemodynamics so it was useful in less stable patients when combined with an opioid. It helped speed induction through the second gas effect. It was not metabolized so renal and liver insufficiency were of less concern.

However, with all of the more recent investigation into reasons for cognitive dysfunction or decline in infants and the elderly following anesthesia, a lot more is now known about the pharmacologic disadvantages of nitrous oxide (1, 2, 3).

Nitrous oxide irreversibly oxidizes the cobalt atom of vitamin B12, transferring it from the active Co(I) state to the inactive Co(II or III) state, inactivating it, somewhat analogous to the reduction of hemoglobin to methemoglobin (4).

Methionine is an essential amino acid that serves as a methyl donor (via its activated form S-adenosylmethionine) in hundreds of biologic reactions. The end product of methionine demethylation is homocysteine, whose remethylation is catalyzed by the vitamin B12 dependent enzyme methionine synthase (synthetase). Inhibition of methionine synthetase by nitrous is irreversible. New enzyme must be produced to replace that which has been inactivated, which can take 2-7 days.

Ninety minutes of exposure to 50% nitrous is enough to halve function of the folate pathway, raising homocysteine levels. Duration of exposure is important.
Elevated homocysteine is associated with vascular events and prolonged recovery.
So far there is no proof in the literature of increased cardiac risk.  Pretreatment with B6 does not change cardiac outcome — even those with mutated folate pathways

HOWEVER, what about CNS risk? Provision of B6 in the stroke literature shows it does help preservation and recovery in the acute stroke patient Elevated homocysteine levels are a risk factor for dementia and Alzheimer’s. Four hours of nitrous in elderly rats causes long lasting (2 wk) memory impairment. Obviously rats are not humans, however it does give one pause before turning that nitrous dial. ten to Twenty percent of adults have folate and B12 deficiency, perhaps predisposing them to injury.

What about some the other issues with nitrous oxide.

  • Nitrous methylates DNA — which may mean that it can have an epigenetic effect to future offspring. That means that methylation of DNA eggs and sperm could potentially cause changes in genetic expression in our sons and daughters, conceived years after the parent’s (or the grandparent’s) anesthetic.
  • N2O is an NMDA receptor antagonist
  • DNA methylation is involved with long term memory storage. Could interference with this process this be the mechanism effecting memory in elderly rats (5)?
  • N2O is a potent green house gas. It remains in the upper atmosphere about 114 years and promotes depletion of the  ozone layer (5,6,7). Click here for a prior discussion of greenhouse effects of nitrous and our other anesthetic agents.

There are times when limited use of nitrous can be useful. I still use it occasionally to speed mask induction of pediatric inhalational anesthetic in the uncooperative child, for instance. I then turn the nitrous off and switch to air/oxygen. I might turn it on at the very end of a case to smooth the wakeup.

My current practice is to avoid use of nitrous

  • serial anesthetics over a short period (less than time frame for regeneration of methionine synthetase)
  • really long cases
  • patient  with known folate and B12 deficiency
  • malnutrition
  • first trimester pregnancy
  • in vitro fertilization
  • renal failure
  • those with inborn errors of metabolism (or untested family members) homocytineuria, an autosomal recessive disease, is the second most common disease of amino acid metabolism. Associated with elevated homocysteine levels and impaired folate pathway
  • patient with hypotonia
  • megaloblastic anemias
  • during anti-folate chemotherapy
  • hypercoagulability or a prothrombotic state

I consider avoiding or limiting exposure to nitrous in:

  • bone marrow harvesting
  • L&D/C-section ( avoiding interference with neurogenesis)
  • Advanced peripheral vascular disease CAD with at risk phenotypes
  • Demyelinating conditions
  • Stroke and CNS surgery
  • Young children and infants during time of major synaptic formation except for short periods during induction and emergence

Finally, one must consider the effects of waste anesthetic gases on health care personnel exposed during the anesthetic (8).

You can correctly infer from that list that I personally don’t use nitrous much at all these days,. If I do it’s not for very long. While it is certainly true that research has not yet shown clear evidence one way or the other that any specific anesthetic causes neurotoxic effects in our patients. Research is ongoing in infants and in the elderly (9, 10).

Nitrous has it’s uses. But consider use only in those patients with minimum risk of harm.

  1. Use of anesthetic agents in neonates and young children.Mellon RD, Simone AF, Rappaport BA. Anesth Analg. 2007 Mar; 104(3):509-20.
  2. Bittner EA, Yue Y, Xie Z. Brief review: Anesthetic neurotoxicity in the elderly, cognitive dysfunction and Alzheimer’s disease. Canadian journal of anaesthesia = Journal canadien d’anesthesie. 2011;58(2):216-223. doi:10.1007/s12630-010-9418-x.
  3. Pinyavat T, Warner DO, Flick RP, et al. Summary of the update session on clinical neurotoxicity studies. J Neurosurg Anesthesiol 2016;28:356-360https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077165/
  4. Baum V: When Nitrous Oxide Is No Laughing Matter. http://www2.pedsanesthesia.org/meetings/2007winter/pdfs/Baum-Friday3-9-07-1050am.pdf
  5. Jevtovic-Todorovic V, Beals J, Benshoff N, Olney JW. Prolonged exposure to inhalational anesthetic nitrous oxide kills neurons in adult rat brain. Neuroscience 2003;122:609-16
  6. Ishizawa Y: General Anesthetic Gases and the Global Environment. Anesth Analg 2011;112:213–7
  7. Sherman J ; Le C; Lamers, V; Eckelman, M: Life Cycle Greenhouse Gas Emissions of Anesthetic Drug. Anesthesia & Analgesia: May 2012 – Volume 114 – Issue 5 – p 1086–1090
  8. Health Effects Associated With Exposure to Anesthetic Gas Nitrous Oxide-N<sub>2</sub>O in Clinical Hospital – Shtip Personel.Eftimova B, Sholjakova M, Mirakovski D, Hadzi-Nikolova M. Open Access Maced J Med Sci. 2017 Oct 15; 5(6):800-804. Epub 2017 Oct 10.

Intubation During Cardiac Resuscitation

Intubating patients during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic technique of intubation. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now? Continue reading

Remember That Respiratory Failure Is Not Always Due to Lung Failure

There are many causes of respiratory failure. Some causes of respiratory failure result from disease or damage to the respiratory system. However disease or injury to other organ systems such as the central nervous system, the musculoskeletal system, or the presence of cardiac or septic shock can also cause respiratory dysfunction.

While final diagnosis will certainly affect treatment, assessing and managing the patient’s ability to breathe will not change with diagnosis.  However, once the airway is secure, you then have to diagnose and treat the real problem in order to resolve the respiratory failure.


The Case

In this case, I was an anesthesia resident doing my pediatric rotation at a children’s hospital. It was my turn to be on call for the weekend. At this particular hospital back in 1982, the anesthesia department managed the airway emergencies in the Emergency Department so when I got the page to go to the ED, I ran.

Inside the triage cubicle a 6 year-old girl was clearly unresponsive. She had been sick with fever, nausea, vomiting and diarrhea for several days according to her mother, who was crying in the corner. She hadn’t been able to hold down any food or fluids for over 24 hours. Her temperature was 102F. She was breathing rapidly but very shallowly. We did not as yet have pulse oximetry, but her color was dusky blue. Her blood pressure was 60/40 and her pulse was 150. She looked septic.

I placed an oral airway and assisted her breathing. She didn’t react at all to the oral airway — no gag reflex. We decided to intubate.

My colleagues quickly placed an IV and I decided to intubate without induction agent or muscle relaxant. If she didn’t need those agents then I didn’t want to potentially compromise her status by giving them. Had she reacted at all when I started to perform direct laryngoscopy I would have aborted and changed the plan.

She didn’t respond at all as I slid the endotracheal tube into the trachea.

We gave her two boluses of 20ml/kg of normal saline. Her color improved, her pulse came down to 110 and her blood pressure rose to 80/50, appropriate for her age. But she still hadn’t woken up.

Ten minutes later the first blood test results returned. Her blood glucose was 10, extremely low. We gave her 2 ml/kg of D25W. Within two minutes she woke up and started fighting the endotracheal tube. As her other vital signs looked much improved and she was now awake and protecting her airway, we elected to extubate her.

The child was admitted to the pediatric ward, was treated for gastroenterits and she did well.


This was the first experience that I remember seeing in my career that demonstrated that hypovolemic shock and hypoglycemia can cause profound respiratory failure without lung pathology.  It’s important to remember that respiratory failure can result from a variety of other systemic problems, not just dysfunction of the respiratory system.

Table showing the difference multi-system causes of respiratory distress and failure

Respiratory distress or failure can come from many causes.

While assisting ventilation and protecting the airway are first priorities to stabilize a patient, treating the cause of the respiratory failure may require more than just ventilation and/or intubation. In fact, treating the cause can sometimes help you avoid the progression of respiratory distress to respiratory failure. If you don’t consider a potential problem or cause, you’re not going to be able to diagnosis it.

May The Force Be With You

Christine Whitten MD
Author of Anyone Can Intubate, 5th Edition



Exhaling During Manual Ventilation Is As Important As Inhaling


One of my readers recently asked a very important question about ventilating a patient with a bag-valve-mask device: “Is there an outlet for the expired air of the patient?” The answer is yes. When ventilating a patient we are concentrating, and rightfully so, on watching the lungs expand and verifying that we hear breath sounds. It is just as important to verify that your patient can exhale. All ventilation devices have a built in pressure relief valve, also called a pop-off valve, which allows you to balance the force needed to expand the lungs with the ability to the patient to passively exhale. Failure to allow exhalation can lead to patient injury from barotrauma.

Self Inflating Bag

Common parts for bag-valve-mask devices, In this case a self-inflating style bag. Note the pressure relief valve near the mask elbow. This valve regulates inspiratory pressure as well as effects ease of exhalation.

Continue reading