Neonatal Airway Basics: ETT Size and Depth Made Simple

In my humble opinion, taking care of a neonate is often easier than taking care of a pediatric patient. That might sound backwards, but it comes down to experience. In a small town hospital like ours, we don’t see critically ill pediatric patients very often. We usually stabilize and ship any neonate or pediatric patient that requires ongoing support. Because of that, pediatrics can feel less familiar and a little more stressful when they do come in.

Neonates, on the other hand, follow a more predictable path in resuscitation. We start with the basics—positive pressure ventilation with a Neopuff. And really, if you are getting good chest rise, you already have an airway. Air is moving. That’s what matters. If the heart rate is improving and the chest is rising, you’re doing your job.

The newer NRP guidelines, I believe the 9th edition, lean toward intubating earlier than the 8th edition. I understand the reasoning, but I don’t always agree with rushing to intubate. If I’m getting good chest rise, I’m not in a hurry. I’ve said it before in those moments: we’re getting good chest rise, everything looks good here, go take care of whatever else you need to do before we intubate. That’s just common sense to me. There’s no reason to rush into intubation when you already have effective ventilation and the provider may have other priorities.

That mindset carries over to adults too. Good bagging goes a long way. There’s no need to fix something that isn’t broken.

Working in a small hospital also shapes how we practice. For years we were told not to intubate and to wait for the transport team. So we did. That might mean Neopuffing for a long time while waiting for the “baby buggy” to arrive from the larger hospital. And honestly, that’s fine. It’s often far easier and less stressful than rushing an intubation and managing a ventilator in a setting that doesn’t do it often.

That said, there are times when intubation is necessary. When ventilation isn’t effective and the baby isn’t improving, there’s no other option. When that moment comes, you need to be ready. That’s where knowing what size ETT to pick and where to secure it becomes important. That’s the purpose of the chart below—it gives you a quick, reliable starting point.

And one last thing that doesn’t get talked about enough is taping the tube. Getting the tube in is one thing, but keeping it in place is just as important. It’s a skill that should be practiced at least once a year, because when you need it, you don’t want to be figuring it out on the fly.

In the end, neonatal resuscitation is about staying calm, doing the basics well, and not rushing into things you don’t need to rush into. When intubation is needed, be ready. But until then, good ventilation solves a lot of problems.

Palbuterol — And Other Things Only RTs Understand

It’s been a while since I created my list of 101 faux versions of albuterol for our Real Physician’s Creed. So I decided to showcase a few more.

Doctors and nurses may be confused… but we know.

If you’ve been around long enough in respiratory care, you start to realize something. Not everything we do is about the medication. Not every treatment fixes what it’s supposed to fix. And sometimes, what actually helps isn’t written anywhere in the order set.

That’s where these come from.

They’re absurd on the surface—but like most good respiratory humor, there’s a little truth hiding underneath.

PALBUTEROL

The medicine may have no effect…
But the company of an RT will.

We’ve all been there.

Treatment ordered. You show up. You assess. You listen. You already know—this isn’t going to change much.

But you stay anyway.

You talk. You reassure. You adjust a pillow. You tweak the oxygen just enough. And somehow… things settle down.

Was it the treatment?

Maybe.

But probably not.

ALLBETEROL

I think that’s all she needs.

There’s a moment in certain rooms where you realize everything doesn’t need to be escalated.

Not every patient needs more machines. More pressure. More noise.

Sometimes they just need someone who knows what they’re looking at… and isn’t panicking.

KNOWBETTEROL

For when you already know… before anyone else does.

You walk in.

Before the chart loads. Before the vitals cycle. Before anyone finishes explaining.

You already have a pretty good idea what’s going on.

Experience does that.

DEEPBREATHEROL

Side effects may include hearing things that weren’t there before.

“Take a deep breath.”

And just like that… crackles, rhonchi, noises everywhere.

Funny how that works.

ORDEROL

Prescribed every four hours… whether it’s needed or not.

No explanation needed.

The Point (Sort Of)

I’ll explain the Real Physician’s Creed more in a future post.

But the short version is this:

It’s not about making fun of doctors. It’s about pointing out the absurdity we sometimes see in medicine… by being just as absurd.

Because if you’ve worked in a hospital long enough, you know—

Some of the most ridiculous things we joke about
aren’t that far from reality.

And sometimes the difference between chaos and calm
isn’t another order…

…it’s just the right person walking into the room.

Singulair: A Medication That Works for Me, Despite the Controversy

It’s honestly hard to write about Singulair.

Any time I’ve mentioned it in asthma groups, the conversation can turn quickly. People share heartbreaking stories about serious side effects, including suicide. Those stories matter, and they deserve to be heard. Losing a child is unimaginable, and I don’t take that lightly.

At the same time, those stories can make people afraid to try a medication that might actually help them. The concern around Singulair is real enough that it now carries a black box warning. But it’s also true that the research hasn’t clearly established a direct cause-and-effect link in every case. Like a lot of medications, it comes down to weighing risks and benefits.

All I can really do is speak from my own experience.

For me, Singulair has worked very well.

Before I started taking it, spring was rough every year. I was constantly sniffling and sneezing, and it felt like I was always trying to stay one step ahead of my symptoms. About 15 years ago, a doctor told me he didn’t think most people noticed much difference with it, so he suggested I could stop. I did, and for a couple of years I got by without it.

At the time, that was fine with me. It was still under patent back then and cost about a dollar a pill, so I wasn’t exactly eager to keep taking it.

Then one summer, my allergies hit hard again. I was going through Sudafed like crazy—probably a box a week—and still felt miserable. One night, I woke up feeling awful and realized I was out of everything. The only thing I had was an old Singulair tablet.

So I took it.

Within about 20 minutes, I felt noticeably better.

That was enough for me. I went back on it and haven’t stopped since.

I understand the concerns. I really do. But I also know what it’s done for me. What frustrates me is that some people who might benefit from this medication may never try it because the conversation around it has become so one-sided. Like anything in medicine, it should come down to an informed decision between a patient and their provider.

Dr. Creed: The Krebs Cycle Theory of Oxygen (2026 Edition)

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Warning: What follows is top secret information recently leaked to me from one of the nation’s most prestigious pulmonologists at a highly respected teaching institution. Read at your own risk. This is not edited.

The following is an excerpt from a lecture given by Dr. Ven Tolin, MD, PhD, MBA, at some point in the recent past.

Transcript:

---

<pre style="font-family: Courier New, monospace; font-size: 14px; line-height: 1.4;">

Read at your own risk. This is not edited.


The following is an excerpt from a lecture given by
Dr. Ven Tolin, MD, PhD, MBA,
at some point in the recent past.


                         T R A N S C R I P T

</pre>
It has come to our attention that respiratory therapists continue to express concern when physicians lower oxygen on patients who appear, at least on the surface, to require it.

This is understandable.

RTs are trained to focus on things like oxygen saturation, work of breathing, and basic human survival. However, what they often fail to grasp is the deeper biochemical strategy at play.

Today I will once again explain why reducing oxygen remains one of the most effective ways to manage elevated CO₂ levels.

It all comes down to the Krebs Cycle.

You may remember this from your early training, although it is unlikely you fully understood it. Oxygen is required for aerobic metabolism, and aerobic metabolism produces CO₂.

So if you think about it:

More oxygen leads to more metabolism.
More metabolism leads to more CO₂.

Therefore, if a patient has too much CO₂, the logical solution is simple:

          Lower the oxygen.

At this point, the RT may begin to object.

They may say things like, “The PaO₂ is 47,” or “The patient looks terrible,” or even “They need oxygen to survive.”

These are surface-level observations.

We must think deeper.

By lowering oxygen, we limit aerobic metabolism and therefore reduce the production of CO₂ at its source. In this way, we are not just treating numbers—we are solving the problem at the cellular level.

In fact, one could argue that the most effective way to eliminate CO₂ is to eliminate the conditions required to produce it.

RTs often struggle with this concept.

They may quietly increase the oxygen when you leave the room. They may document concerns. They may even attempt to explain physiology.

Remain calm.

You are the physician.

If necessary, place a note in the chart stating:

          "DO NOT INCREASE OXYGEN UNDER ANY CIRCUMSTANCES."

This usually restores order.


A word of caution: do not attempt to fully explain this theory to a respiratory therapist. Excessive exposure to advanced medical reasoning may result in confusion, frustration, or spontaneous eye rolling. In rare cases, it may cause the RT’s head to swell to dangerous proportions.

We do not want that.


In conclusion, while RTs may continue to rely on outdated concepts such as oxygenation, ventilation, and patient comfort, we as physicians must remain committed to higher-level thinking.

Remember:

          Not everything that appears necessary... actually is.



                         END TRANSCRIPT



Editor’s note (RT Cave, 2026):

Sometimes the best way to understand a bad idea...
is to take it seriously all the way to the end.

---

Editor’s note (RT Cave, 2026): Sometimes the best way to understand a bad idea… is to take it seriously all the way to the end.

Weird Is Fine

For a long time I thought being “weird” was something I needed to fix.

Too quiet.
Too anxious.
Too sensitive.
Too observant.
Too emotional.
Too interested in old things.

I spent years comparing myself to people who seemed more normal than me.

My brothers were outside socializing while I often stayed in my room reading, writing, collecting old photographs, or listening to family stories from my grandma. While other people threw things away, I saved them.

Letters.
Cards.
Old newspaper clippings.
Hospital paperwork.
Photographs.

At one point when I was a teenager at National Jewish Hospital in Denver, some of the staff even encouraged me to throw away old letters I had saved from home.

I refused.

At the time, maybe that seemed strange.

Now I’m grateful I kept every one of them.

Because years later, those same letters helped me reconstruct huge portions of my life and eventually helped me write my memoir.

The older I get, the more I realize something important:

A lot of people who create things were “weird” kids.

The kid who notices everything.
The kid who stays inside reading.
The kid who watches instead of joins.
The kid who remembers details nobody else remembers.
The kid who talks to grandparents instead of going to parties.
The kid who saves things everybody else throws away.

That was me.

My childhood honestly was a little weird.

I was often the kid sitting alone on the bench while everybody else played.

Sometimes the playground monitors even tried involving me because they felt bad for me. But most of the time I was honestly fine just sitting there watching everything.

Part of that was asthma.

Part of it was anxiety.

Part of it was simply my personality.

And honestly, asthma probably shaped some of that.

I was quiet.
Introverted.
Short.
Sensitive.
Always sniffling or congested from allergies.

And kids noticed.

So I got picked on sometimes too.

Honestly, that only made isolating myself even easier.

Back then, even I thought something about me was probably different in a bad way.

But the older I got, the more I slowly accepted something important:

This is just who I am.

And honestly, “weird” now looks a lot like this:

Sitting by myself late at night writing stories, preserving memories, researching family history, saving old letters, and trying to understand a life that once confused me.

When you spend a huge part of childhood sick, short of breath, anxious, or left out, you develop differently.

You spend more time inside your own head.
You observe people.
You listen carefully.
You notice details other people ignore.

At times in my life I hated that about myself.

Now I don’t.

Because the truth is, if I had been completely normal, I probably would not have a story worth telling.

I would not have saved the letters.
I would not have preserved the memories.
I would not have become a writer.
I would not have spent years researching family history.
I would not have created Respiratory Therapy Cave.
And I definitely would not be sitting here writing this today.

Weird is not always bad.

Sometimes weird simply means you grew in a different direction than everybody else.

And sometimes that difference becomes the very thing that gives your life meaning later on.

When I first started writing my memoir, part of me wanted to normalize myself.

Make myself cooler.
More social.
More confident.

Maybe give myself a girlfriend.
Make myself one of the kids sneaking off campus.
Make myself the tough funny guy always saying the smart thing at exactly the right moment.

But that was never really me.

Instead, I finally let the real story come out.

The awkward skinny kid.
The anxious kid.
The socially uncomfortable kid who often sat quietly watching instead of participating.

And honestly, once I stopped trying to rewrite myself, the story became much easier to tell.

Probably because it finally became true.

 The truth is, I probably did have some strengths because I was different.

I noticed things.
Remembered things.
Saved things other people threw away.

But what finally made the memoir work was realizing I did not need to rewrite myself into some cooler version of a teenager.

The awkwardness mattered too.
The anxiety mattered too.
The loneliness mattered too.

Because that was the real story.

And honestly, if I had turned myself into the confident tough guy with a girlfriend sneaking off campus every night, the memoir probably would have become far less interesting anyway.

Not because my struggles made me special.

But because the things that made me different also shaped the way I experienced the world.

And maybe that difference is exactly what made the story worth telling in the first place.

How Do We Take the Power Back from Insurance Companies?

One thing we do in this country—we see a problem and immediately say, “we’ve gotta do something.”

But sometimes it’s better to do nothing than to do something stupid.

And by stupid, I mean piling on another law, another regulation, another layer. That’s the default move. Problem? Add something. Fix it with more rules.

That’s the wrong approach.

Because most of the time, we don’t actually fix the problem. We just create new ones. Unintended consequences. More complexity. More people in the middle. More control.

And somehow, every time we “do something,” healthcare gets more expensive, not less.

We—the patient—we’re the ones who get squeezed. More rules, less access. More options on paper, harder to actually get what we need.

So how do you fix something like this?

Because let’s be honest—this thing is a mess.

Too many layers. Too many middlemen. Too many people getting between a doctor and a patient.

If you ask me, the first step is simple.

Get the middle out.

Right now you’ve got insurance companies, PBMs, and a maze of rules deciding what you can and can’t have. That’s backwards. The doctor should make the call. The patient should be able to get it.

If there’s going to be money in the system—especially taxpayer money—then put it directly in the hands of patients. Give people a fixed amount and let them choose their insurance. Let companies compete for your business instead of trapping you in a system where they call all the shots.

Competition works better than control. It just does.

Second, price transparency. No more guessing games. No more “we’ll let you know after we deny it.” If a medication costs $50, say it. If it costs $500, say it. If it costs $1700, say it upfront. Let people make decisions with real information.

Third, limit the gatekeeping. Prior authorization, step therapy, all of it. If a doctor documents that something is medically necessary, that should carry real weight. Not six phone calls, three faxes, and a denial anyway.

Now, when it comes to government, I’m not saying burn it all down. I want medications to be safe. Nobody wants unsafe drugs on the market.

But there’s a difference between safety and control.

Right now, the system leans heavily toward control.

A better balance would be this: government focuses on safety, transparency, and basic guardrails. Make sure drugs are what they say they are. Make sure they’re not dangerous. Then get out of the way.

Educate people. Give them information. Let doctors practice medicine. Let patients make decisions.

Because right now, we’ve got a system that says it’s protecting us—but in reality, it’s just making it harder to get treated.

More medications than ever. More options than ever.

And still…

Too many people walking away saying:

“I finally found something that works… and I can’t get it.”

We don’t need more control. We need less interference between the doctor, the patient, and the treatment.

2026 — The Many Types of Albuterol (According to Everyone But RT)

If you’ve worked in respiratory therapy long enough, you start to notice a pattern.

Wheezing? Albuterol.
Short of breath? Albuterol.
Fever? …still albuterol.

At some point, you realize we’re not just giving treatments—we’re following tradition.

Over the years, a more accurate classification system has quietly developed.

---

1. 0.5cc Ventolin

Symptom: Wheeze / SOB
Diagnosis: Bronchospasm
Frequency: Q4 & PRN
Effect: Actual bronchodilation. The original. The reason this all started. It works great for asthma, but is used for all annoying lung sounds and when the patient is short of breath and the doctor doesn't know what else to do. 

---

2. 0.5cc Preventolin

Symptom: Surgery
Diagnosis: General
Frequency: Q4
Effect: Prevents pneumonia, atelectasis, pulmonary embolus, MI, rickets, and possibly bad weather.

---

3. 0.5cc Mystolin

Symptom: Fever
Diagnosis: Non-specific
Frequency: Q4
Effect: A study showed that 100% of patients who received Mystolin eventually recovered.

---

4. 0.5cc Cardiacolin

Symptom: “Cardiac wheeze”
Diagnosis: CHF / Pulmonary edema / MI
Frequency: Q4 ATC
Effect: Even though fluid is the problem, the treatment remains the same.

---

5. 0.5cc Meetcriteriolin

Symptom: Vague complaints
Diagnosis: Pneumonia (despite normal X-ray, labs, and lungs)
Frequency: Q4 ATC
Effect: Ensures all boxes are checked. Outcome optional.

---

6. 0.63mg NoShakenex

Symptom: Shakes
Diagnosis: Side effect of albuterol
Frequency: Q4
Effect: Same medication, different name, same result.

---

7. 2.5mg Atrovent (Solo Edition)

Symptom: Anything or nothing
Diagnosis: “Allergy” to albuterol
Frequency: Q4–6
Effect: Backdoor bronchodilation. Also effective at testing RT patience.

---

8. 0.5cc Coolovent

Symptom: Fever
Diagnosis: Post-op
Frequency: Q4
Effect: Mechanism unclear. Provider reassurance high.

---

9. CVA-Albuterol

Symptom: Rhonchi
Diagnosis: Weak cough / poor airway clearance
Frequency: Q2–4
Effect: Followed by suctioning to eliminate concerning sounds.

---

10. 0.5cc Scrubbin-Bubblin

Symptom: Productive cough
Diagnosis: “Junky” lungs
Frequency: Q4
Effect: Bubbles imply progress. Doctors think the foaming bubbling action cleans out the lungs just like scribbin bubbles gets all the dirt and grime out of a dirty sink. 

---

11. 0.5cc O-Buterol

Symptom: Mouth open, sleeping comfortably
Diagnosis: Existing in a hospital bed
Frequency: Q4 ATC
Effect: Maintains tradition. If a patient has an O they must need albuterol.

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More to come…

Because this list didn’t stop at 11.
Not even close.

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Source:

Inspired by an older RT humor piece, updated and expanded with real-world observations