Every Couple Years — A Pediatric Airway Refresher (ETT Size and Depth)

I work for a small-town hospital. I believe we only have 34 patient rooms upstairs. We no longer admit pediatrics—if they need hospitalization, they’re sent to the Big City. But we still have an ER, and every once in a while we get a pediatric patient—anywhere from a 1-week-old to an 18-year-old—and sometimes they require invasive procedures, including intubation.

So yes, we have the Broselow Tape. It’s a great tool. You lay it out, line it up with the child, and it tells you exactly which drawer to open. Everything you need is right there. Clean. Organized. Foolproof.

I was talking about this with one of my coworkers, and she said she just waits for the doctor to call out what size ETT he wants.

That’s not good enough for me.

Knowing and being prepared means staying calm myself. There’s always a bit of nerves when you’re dealing with someone’s child. That never really goes away—and maybe it shouldn’t. But preparation takes the edge off. It lets you stay steady when the room isn’t. It gives you something to fall back on when things start moving fast.

Every couple of years, it’s worth dusting this off. Pediatric airways are not something you want to be figuring out in real time with a room full of eyes on you. The Broselow Tape is great—and you should absolutely use it—but having a mental backup based on age keeps you one step ahead when things get loud.

Start simple. For uncuffed tubes, the classic formula still works: internal diameter ≈ (age ÷ 4) + 4. For cuffed tubes, subtract about half a size: (age ÷ 4) + 3.5. It’s not perfect, but it gets you close enough to act. A 4-year-old? You’re thinking around a 5.0 uncuffed or 4.5 cuffed. An 8-year-old? Around a 6.0 uncuffed or 5.5 cuffed. You can fine-tune from there based on leak and feel, but you’re not starting from zero.

Depth is where trouble sneaks in. A quick rule: depth at the lip in centimeters ≈ tube size × 3. Drop a 4.5, you’re thinking around 13–14 cm. A 5.5 lands around 16–17 cm. It’s a guide, not gospel—but it helps you avoid the classic right mainstem surprise while you’re still getting your bearings. You confirm with breath sounds, chest rise, end-tidal CO₂, and X-ray, but at least you’re starting in a safe zone.

And in kids, we’re talking lip, not teeth. Teeth are unreliable—missing, loose, or not even there yet. The lip becomes your consistent landmark. Say the number out loud. Document it. Make sure the room hears it. Tubes move, especially in small patients, and you want everyone on the same page.

A few quick anchors help when your brain blanks. Neonates usually fall in the 3.0–3.5 range, with depths around 9–11 cm depending on size. There’s also the weight trick: depth ≈ weight (kg) + 6. By about one year old, you’re typically at a 4.0 cuffed tube. From there, the age-based formulas carry you forward. By the teenage years, you’re basically in adult territory.

Cuffed versus uncuffed used to be a bigger debate. These days, cuffed tubes are common even in younger kids—as long as you respect cuff pressures and size appropriately. You get better control, less leak, and more consistent ventilation. The tradeoff is simple: don’t overdo it. Gentle inflation. Respect the airway.

The pediatric airway isn’t just a smaller version of an adult airway—it’s different. Bigger occiput, more anterior larynx, relatively larger tongue. Positioning matters. A small shoulder roll in infants can make all the difference. If your view is poor, it’s often positioning—not equipment.

The point of all this isn’t to replace the Broselow Tape. It’s to back it up. When things are calm, you use every tool you’ve got. When they’re not, you fall back on what’s in your head. Having a working mental model for tube size and depth doesn’t just make you faster—it makes you calmer. And in those moments, calm is everything.

Do people really die peacefully?

We hear it all the time. “He passed away peacefully, surrounded by family.” It’s a comforting thing to say. It’s gentle. It helps loved ones, especially children, make sense of something that doesn’t make sense. I’m not saying it’s wrong. There’s value in that.

But I want to talk about the reality we see.

I’m an RT. Like most of you reading this, I’ve seen death many times. And yes, sometimes people really do die peacefully. I remember one patient who told me he was ready. He wasn’t dramatic about it. Just calm. He went to sleep, and I watched his monitor slow down and then go flat. No struggle. No panic. Just… done. That was peaceful.

But that’s not how it always goes.

You walk into a room and see a 92-year-old man who can’t get comfortable. He’s restless, shifting, breathing hard. You can tell he’s not okay. The doctor orders morphine or something for anxiety. You give it. He settles down. Not long after, he dies. And then the chart reads, “Patient passed away peacefully surrounded by family.” Maybe in that final moment he was. But right before that, he was miserable.

Then there are the diseases we know too well. Lung cancer. Pulmonary fibrosis. End-stage COPD. These are not easy ways to go. These patients feel like they’re suffocating, because they are. Air hunger is real. It’s one of the worst feelings a person can have. You can see it in their eyes. The panic. The fight for every breath. We give morphine. We give benzos. We do what we can to take the edge off. And sometimes we help a lot. But that doesn’t mean the whole process was peaceful.

So why do we say it?

Because it helps people. It softens the memory. It gives families something to hold onto that isn’t fear or suffering. And I get that. I really do.

But here, we can be honest about it.

Death isn’t always peaceful. Sometimes it’s uncomfortable. Sometimes it’s a struggle. Sometimes it’s a fight right up until the end. And sometimes our job isn’t to make it peaceful. It’s to make it less bad.

That’s the reality we see. The reality we treat. The knowing what few know.

Things Most Respiratory Therapists Have in Common

Spend enough time in a hospital, and you’ll start to notice something.

Respiratory therapists don’t all act the same—but we think the same.

You can drop us into any room, any shift, any hospital… and within a few minutes, we’re doing things almost identically. Not because we were taught to follow a script, but because experience forces you into patterns that actually work.

Here are a few of them.

1. We listen to lung sounds bottom to top, side to side—and we don’t immediately tell the patient to take a deep breath.
   Because we want to hear what’s really there first.
2. We know that the second a patient takes a deep breath, you’ll suddenly hear crackles and rhonchi that weren’t there before—and that’s not bronchospasm.
3. We understand that true bronchospasm wheezes are subtle.
   You hear them through the stethoscope—not across the room.
4. If a wheeze is audible without a stethoscope, we’re already thinking:
   upper airway noise, secretions, or fluid—not bronchospasm.
5. After checking for wheezes (which, honestly, aren’t present in most treatments),
   then we ask for deep breaths—because that’s when the hidden stuff shows up.
6. We develop a kind of clinical detachment.
   Not because we don’t care—but because we’ve seen enough to stay calm when things get weird.
7. Our sense of humor gets dry.
   Sometimes really dry.
   Sometimes only another RT will get it.
8. We quietly believe we know more about respiratory care than most people in the building.
   And if we’re being honest… we usually do.
9. We definitely think we know more than nurses about respiratory.
   (No offense. Different lanes.)
10. We can often tell the difference between pneumonia, CHF, and bronchospasm before the chart even loads.
11. We’ve given so much Albuterol (Ventolin) that we’re pretty sure it has granted us some kind of higher-level awareness.
12. We can walk into a room and know in about five seconds whether the treatment is actually needed.
13. We’ve mastered the art of doing a treatment… while also fixing three other problems no one asked us to fix.
14. We’ve all had that moment where we adjust the oxygen, step back, and think:
    “This is going to be fine.”
    And most of the time… it is.
15. We could probably run the hospital better than administration.
    But we absolutely do not want their jobs.
16. When people in suits show up—administrators, inspectors, whoever—
    we suddenly remember we have somewhere else to be.
    We don’t run… but we definitely reposition strategically.
17. We become masters at bedside conversation.
    One-on-one, patient to therapist—we know how to read the room, keep it real, and make people feel at ease in about 30 seconds.
18. Like journalists, we learn how to end conversations cleanly.
    “Well, I gotta get to my next patient…”
    (We’ve used that line a thousand times—and it always works.)
19. We can tell within seconds what kind of patient we’re dealing with—
    talker, quiet, anxious, skeptical—and we adjust instantly.
20. We’ve perfected the art of looking busy…
    because most of the time, we actually are—but it also helps when you need to avoid getting pulled into something unnecessary.

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The Funny Part

Most of this isn’t written anywhere.

It’s not in textbooks. It’s not in policies. It’s not something you learn in school.

It’s what happens after hundreds—maybe thousands—of patient interactions. After listening to lungs long enough that patterns start to jump out at you. After giving enough treatments to know which ones matter… and which ones are just being done because “that’s what we always do.”

That’s when you stop just doing the job…

…and start understanding it.

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Final Thought

If you know, you know.

And if you’re an RT reading this, you probably nodded your head at least a few times.

Because whether you’re in Michigan, Florida, or anywhere in between—
we’re all practicing the same unwritten version of respiratory care.

And somehow… it works.

Who Gave Insurance Companies All This Power?

In my last post I talked about how insurance companies now decide what medications we get, when we get them, and how hard we have to fight to get them.

So who gave them that power?

This didn’t come from one law. It came from a series of laws—passed over decades—by both Democrats and Republicans.

Start with ERISA (Employee Retirement Income Security Act, 1974). That was passed by Congress and signed by a Republican president (Ford). It had broad bipartisan support. That law allowed large employers to run their own health plans and limited what patients can do when claims are denied. That’s a big one. Most people have never heard of it, but it quietly took power away from patients and states and centralized it.

Then in the 1980s and 1990s you get the rise of managed care. Not one single law, but a shift supported by both parties—Republicans and Democrats—pushing HMOs and cost control. That’s when networks, referrals, and utilization review really took off. That’s where the insurance companies started saying, “We’re not just paying—we’re deciding.”

Then you get Medicare Modernization Act (2003) under a Republican Congress and President Bush. That created Medicare Part D and locked in the role of pharmacy benefit managers (PBMs). It also specifically prevented Medicare from directly negotiating drug prices. That decision pushed more control into the hands of insurers and PBMs.

Then comes the big one everyone talks about—the Affordable Care Act (ACA, 2010) under Democrats.

No, it didn’t create prior authorizations or formularies. Those already existed. But it did a few things that made the system tighter.

It expanded coverage to millions more people. It added essential benefit requirements. It added regulations on insurers.

That sounds good—and some of it is.

But here’s what also happened.

More people in the system. More rules. More cost pressure.

And when you put pressure on cost, the system responds the only way it knows how:

It tightens control.

That’s where you see more:

• prior authorizations
• step therapy
• narrower formularies
• quantity limits

So no, Obamacare didn’t start this.

But yes, it added fuel to it.

Then you’ve got the role of agencies like the FDA and HHS.

Congress passes broad laws. Agencies write the rules. Those rules aren’t technically laws, but they function like them. That’s how our system works. Both parties have supported that structure for decades.

The FDA decides how drugs get approved, labeled, and brought to market. HHS oversees the system. CMS runs Medicare and Medicaid rules.

Insurance companies then build their policies around all of that.

So now you’ve got:
Congress writing broad laws
Agencies writing detailed rules
Insurance companies enforcing them
PBMs controlling drug access

And the patient stuck in the middle.

I’m not saying we don’t need regulation. I want safe medications. I don’t want garbage drugs getting pushed on people.

But somewhere along the way, it stopped being about safety and started being about control.

And both parties had a hand in building it.

Republicans pushed market-based systems, employer plans, and PBMs.

Democrats expanded coverage, added regulations, and increased system complexity.

Put it all together over 40–50 years and you end up with what we have now.

More medications than ever. More inhalers than ever. More options than ever.

And somehow it’s harder than ever to get the one your doctor says you need.

This didn’t just happen.

It was built.

How Many Inhalers Have I Used in My Lifetime? A Lot

It started for me around 1980.

That’s when I was first introduced to inhalers. Back then it was simple. You had a rescue inhaler—mine was Alupent. Then that shifted to albuterol, which is what most people still use today. Same idea, different name.

Then came the inhaled corticosteroids. At first it was just one inhaler, one job—reduce inflammation. But over time, that changed too.

We went from single inhalers… to long-acting bronchodilators… to combination inhalers with LABA and inhaled corticosteroids… and now triple therapy with three medications in one inhaler.

And that’s just the surface of it.

Because then you add in all the generics. I’ve probably taken most of them at one point or another. Same drugs, different names depending on who made them. Beclomethasone, budesonide, fluticasone—brand name, generic name, back and forth. Albuterol alone comes in a dozen versions. Then different devices—MDIs, dry powder inhalers, mist inhalers. Then the propellant changes. Then patents come and go. Then years where there are no generics… and then suddenly there are again.

At this point, there are so many inhalers and combinations that it would be impossible for anyone to try them all. And there are probably more than I even realize.

So what have I actually used over the years?

Quite a few.

• Vanceril—and all the versions of beclomethasone that came with it, usually that pink inhaler
• Beclovent—another version of beclomethasone, brown inhaler
• Azmacort—triamcinolone, white inhaler with a spacer
• Aerobid—flunisolide, and yeah, that one tasted awful
• Flovent—fluticasone, plus the generic fluticasone versions that came later
• Serevent—salmeterol
• Advair—fluticasone/salmeterol, and the generic versions of that combo
• Singulair—montelukast (not an inhaler, but part of the routine for a while)
• Dulera—mometasone/formoterol
• Breo—fluticasone/vilanterol
• Trelegy—fluticasone/umeclidinium/vilanterol
• And now Breztri—budesonide/glycopyrrolate/formoterol

If you add in all the generics, the list is much longer:

Alupent, Proventil, Ventolin, ProAir HFA, ProAir RespiClick, ProAir Digihaler, Xopenex, Maxair, Primatene Mist, Primatene Mist HFA, Vanceril, Beclovent, QVAR, Azmacort, Aerobid, Flovent HFA, Flovent Diskus, Pulmicort Turbuhaler, Pulmicort Flexhaler, Serevent Diskus, Foradil Aerolizer, Intal, Tilade, Advair Diskus, Advair HFA, Wixela Inhub, , Symbicort, generic budesonide/formoterol inhalers, Dulera, Breo Ellipta, , Trelegy Ellipta, Breztri Aerosphere, generic albuterol sulfate HFA inhalers, generic fluticasone propionate HFA inhalers, , generic beclomethasone inhalers, generic flunisolide inhalers, generic triamcinolone inhalers

And on top of that, all the albuterol inhalers over the years—Proventil, Ventolin, ProAir, and all the generics that look slightly different but do the same thing. Heck, there used to be tons of albuterol generics, each one a unique color. 

I switched from Trelegy to Breztri because Trelegy is a dry powder inhaler and it made me cough. Breztri is a metered-dose inhaler with a mist, and it’s just easier for me to tolerate.

When you step back and look at it, it’s kind of crazy. We went from a couple of inhalers to all these options, combinations, and delivery systems.

You’d think that would make things easier.

But somehow, it’s gotten more complicated—and in a lot of cases, harder to get the one that actually works for you.

O-Buterol: Because Everything Gets Albuterol

When Did Insurance Start Practicing Medicine?

There was a time—not that long ago—when this was simple.

You went to your doctor. They wrote a prescription. Your insurance covered it.

I remember getting three albuterol inhalers at a time. No hoops. No questions. Just care. Doctors had samples in the office. If you needed something, they handed it to you. You walked out treated.

Now it’s one inhaler, maybe. Prior authorizations. Step therapy. Denials. Appeals. Delays.

Somewhere along the way, the system flipped.

And I keep coming back to the same question: when did insurance companies start practicing medicine?

This didn’t happen overnight. It was a slow shift, and like most things in healthcare, it came down to money and control. Drug costs went up, insurance companies pushed back, and instead of working with doctors, they built systems to manage what patients could and couldn’t get.

That’s where formularies came from. Lists of approved medications. Not approved by your doctor, but by the insurance company. Then they added tiers—cheap drugs, expensive drugs—and suddenly what you got wasn’t just about what worked, it was about what cost less.

Then came prior authorization. This is where your doctor says, “My patient needs this,” and the insurance company says, “Prove it.” So now your doctor’s office is filling out forms, sending faxes, making calls, and waiting. Meanwhile, you’re waiting too. And after all that, you can still get denied.

And then there’s step therapy. This one is just stupid. “Try the cheaper drug first. If it doesn’t work, then we’ll consider the one your doctor actually wanted.” That’s not medicine. That’s a cost-control strategy pretending to be medical judgment. It delays care, frustrates patients, and puts barriers between you and treatment for no good reason other than saving money.

Behind the scenes, there’s another layer most people don’t even know about: pharmacy benefit managers, or PBMs. These are the middlemen. They decide what drugs are covered, what pharmacies you can use, and how much things cost. They negotiate deals and rebates, and they make money in the middle. So decisions about your medication aren’t just about what works—they’re tied up in contracts and margins.

Even the little things disappeared. Doctors used to give out sample medications all the time. That’s mostly gone now. Partly because of tighter regulations, partly because of liability, but also because the system has shifted toward tracking everything, billing everything, controlling everything. Free samples don’t fit well in that kind of system.

So here we are.

We’ve moved from a system where doctors made decisions and patients got treated, to one where insurance companies decide what gets approved, how much you get, and how long you have to wait. Doctors still make recommendations, but they don’t have the final say anymore.

And patients notice. You feel it when you can’t get the medication your doctor prescribed. You feel it when you’re stuck waiting for approval. You feel it when you’re told to try something that doesn’t make sense just to check a box.

That’s why people are starting to go around the system. Cash pay. Online pharmacies. Compounding pharmacies. Not because they want to be difficult, but because they’re trying to get treated without jumping through a dozen hoops.

I’m not saying the old system was perfect. It wasn’t. But it was simpler. It was faster. And in a lot of ways, it made more sense.

Now we’ve got a system where the people paying the bills are calling the shots, and the people actually taking care of patients have to ask permission.

And that’s the part that doesn’t sit right.

Because at the end of the day, it shouldn’t be this hard to get something your doctor says you need.