When Weight Leads You Astray: Avoiding Pediatric Airway Tube Size Errors
A 3-year-old child was intubated with a 6.5 cuffed endotracheal tube.
He survived, but the consequences were devastating: permanent vocal cord damage and tracheal stenosis.
This isn’t an isolated event; literature confirms that choosing an inappropriately large tube can result in airway trauma and long-term injury¹.
The reason for the incorrect tube selection is nuanced, but it stems from a classic mistake many clinicians make when sizing pediatric equipment.
The Weight Trap
In a pediatric resuscitation, one of the first cries you’ll hear is:
“We need the child’s weight!”
In this case, the triage nurse relayed:
“Mom said he’s 66 pounds, so let’s call it 30 kg.”
And that’s where the domino effect began.
Why Weight Can Mislead
Weight is critical for medication dosing, but it can be dangerous when used for equipment sizing.
Here’s why:
- Medications: A 30 kg dose may be appropriate if the child actually weighs that much.
- Equipment: A 3-year-old’s airway, regardless of excess body weight, is sized for an ideal body weight (IBW) of ~15 kg.
When the team used 30 kg to select the airway, they chose a tube far too large, and the child’s airway paid the price. Studies consistently show that airway size correlates with age and length, not weight²,³.
The Cardinal Sin
Equipment sizing must never be based on weight.
- Drugs → weight
- Devices → age/length
Confusing the two is a cardinal sin that can turn a resuscitation into a tragedy. The most recent ILCOR 2025 Pediatric Life Support consensus explicitly reinforces that endotracheal tube size should be based on age or length, not actual body weight⁴. The 2021 European Resuscitation Council (ERC) Pediatric Life Support guidelines echo this recommendation⁵.
A Systems Problem
Here’s the catch: many tools in use today start with weight alone, leaving clinicians vulnerable to this exact error. Judicial reviews of malpractice cases have even identified inappropriate tube size in pediatric intubations as a recurring claim⁶.
Safer systems take a different approach: they incorporate age or length into the calculation so that the drug dosing and the equipment recommendations diverge when they should. When those details are built in, the risk of confusing “weight for meds” with “weight for equipment” essentially disappears.
Real-World Case: The $16 Million Verdict
Case Summary: A 6-year-old girl was intubated after a fall. The first tube was advanced into the right mainstem bronchus—too deep for her anatomy. Ventilation was compromised, and confirmatory imaging was delayed. She suffered hypoxia and permanent brain injury.
In court, experts emphasized the importance of selecting the correct tube size for pediatric patients. The hospital conceded liability, and a jury awarded $16 million to the family⁷.
This case underscores that tube mis-sizing and misplacement are not rare errors—they are catastrophic ones.
Closing Thought
This child’s case is not just a cautionary tale; it’s a reminder that in pediatrics, bigger does not mean older.
A child’s weight may fluctuate, but their airway dimensions track with age and length. Get that wrong, and the consequences can last a lifetime.
References:
- Khine, H. H., Corddry, D. H., Kettrick, R. G., Martin, T. M., McCloskey, J. J., Rose, J. B., … & Zagnoev, M. (1997). Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology, 86(3), 627–631.
- Shibasaki, M., Nakajima, Y., Ishii, S., Shimizu, F., Shime, N., Sessler, D. I., & Toyooka, H. (2010). Prediction of pediatric endotracheal tube size by ultrasonography. Anesthesiology, 113(4), 819–824.
- Van de Voorde, P., Turner, N. M., Djakow, J., de Lucas, N., Martinez-Mejias, A., Biarent, D., … & Zideman, D. (2021). European Resuscitation Council Guidelines 2021: Paediatric life support. Resuscitation, 161, 327–387.
- International Liaison Committee on Resuscitation (ILCOR). (2025). Pediatric Life Support: 2025 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (COSTR) [Preprint].
- Cho, Y., Jung, J., Kim, D., Kim, H., Kim, J., Park, J., … & Lim, T. H. (2021). Analysis of endotracheal intubation–related judicial decisions: An observational study. Acute and Critical Care, 36(4), 334–343.
- Clinician.com. (2020). Incorrect intubation results in brain damage – $16 million award.
Peter Antevy, MD
DISCLAIMER: These links are provided for research and do not have affiliations with Handtevy.