Site Home

Neonatal Handbook

Network Services > Newborn Emergency Transport Service > NETS Handbook

 

Intubation

Summary

  • in an emergency oral intubation is the route of choice
  • if unfamiliar with technique of intubation use bag and mask until adequate help arrives. The majority of infants can be managed with bag and mask ventilation
  • muscle relaxants are contraindicated in situations known to be associated with difficult intubation (e.g. Pierre Robin sequence) or when the operator is inexperienced with these medications
  • the commonest reason for the clinical condition not to improve after intubation is because either the oesophagus or the right main bronchus has been intubated

Introduction

Endotracheal (ET) intubation is an important procedure in the care of the newborn.

Equipment

  • laryngoscope Handle: Penlon miniature with hook-on fitting
  • blades: 00, 0 (Premature), 1 (Neonatal)
  • introducer (in sterile package) for oral intubation, it must be inserted to 1cm less than the length of the ET tube
  • Magills forceps for use during nasotracheal intubation
  • endotracheal tubes: Portex Paediatric, Sizes 2.5, 3.0 and 3.5mm
  • connectors to fit between ET tubes and ventilation bag and circuit, Neopuff or mechanical ventilator
  • tapes for securing ET tubes - Sleek "trousers", Leukoplast or Elastoplast, tie
  • skin prep swabs
  • End Tidal CO2 detector

go to top

Monitoring

During an acute cardiorespiratory arrest or in the delivery room monitoring may not be achievable.

In controlled situations, before commencing intubation, place infant under radiant warmer, obtain IV access, attach cardiorespiratory and oxygen saturation monitors and record full baseline observations.

Endotracheal Tube Size and Length

Most babies <1250 grams (<32 weeks) will need a 2.5 mm ID (internal diameter) ET tube. 1250 - 3000 grams (32-38 weeks) a 3.0 ID tube and >3000 grams (>38weeks) a 3.5 ID tube.

 Baby Weight
(kg)

 Tube Size
(mm)

 Oral Tube Length at Lip
(cm)

 Nasal Tube Length at Nose
(cm)

 Suction Tube Size
(Fr)
 <1.0 2.5 5.5 7.0  6 
1.0   2.5-3.0  6.0 7.5 6
2.0  3.0  7.0 9.0 6
3.0  3.0  8.5  10.5 6
3.5  3.0-3.5  9.0  11.0 8
4.0  3.5  9.0  11.0 8


An alternative is to assess ET tube length by the rule of six.

Oral tube length(cm) =: 6 + wt (kg)

Nasal tube length(cm) = 6 + (1.5 x wt)

The formulas are general guides only and appropriate position must always be confirmed clinically and radiologically. The oral tube formula may produce a low lying tube while the nasal tube formula may result in a high tube.

go to top

Procedure

Observe standard precautions.

Maintain sterility of equipment until use. Use a new ET tube for each intubation attempt.

Aspirate stomach contents prior to procedure if the infant has been fed recently.

Place infant’s head in the slightly extended ‘sniffing’ position but remember that one of the commonest errors of endotacheal intubation is over-extension of the upper airway.

Pass laryngoscope blade gently along the side of the mouth and gently pull tongue and epiglottis forward by lifting the blade. If the vocal cords and epiglottis do not come into view pull the laryngscope back gradually until they are seen to avoid intubation of the oesophagus. Application of cricoid pressure may be helpful.

If the infant remains bradycardic for more than 30 seconds during the procedure and intubation is not near complete remove tube and ventilate the infant by bag and mask until HR, colour and oxygen saturation are within normal limits.

Following insertion of the ET tube, place a cotton tie securely (but not tightly) around the tube. After drying the face, apply hydrocolloid dressing strip.

  • adhere the unsplit section of one Sleek "trouser" to the cheek and one tab above the upper lip. Wrap the other tab in a spiral around the ET tube

Image displaying intubation procedure

  • take the second Sleek "trouser" and adhere the unsplit section to the cheek. Place one tab below the lower lip and wrap the other tab in a spiral around the ET tube

Image displaying intubation procedure

go to top

Confirmation of tube position

The ET should be passed so that the tip lies approximately midway between the vocal cords and the carina. Tube position can be confirmed by:

  • ensuring the ET tube tip is no more than between 2.5 to 3.0cm beyond the vocal cords (to avoid intubation of the right main bronchus)
  • use of End Tidal CO2 detector
  • observing symmetrical chest-wall motion
  • hearing equal air entry on both sides of chest and not over stomach (may be an unreliable sign in tiny infants)
  • seeing moisture in the ET tube during exhalation
  • improvement of clinical condition
  • chest x-ray (ET tube tip is seen at the level of T2-T3)

go to top

Areas of Uncertainty in Clinical Practice

Oral versus Nasal Intubation:  The route chosen will depend on the training and skill of the operator since both routes are safe and effective ways to deliver assisted ventilation. In an emergency oral intubation should be performed.

Premedication/Sedation:  Intubation causes physiological destabilisation and is distressing and painful. There are several reports that such changes can be reduced by premedication with a variety of agents. Superiority of one particular regime has not been established. 

  • at delivery or in other life threatening situations intubation without sedation is warranted
  • in controlled situations consider premedication – the decision will depend on the experience and training of the operator. Since intubation is made more difficult by an active patient, premedication is particularly relevant for mature infants
  • sedation with paralysis (preferred option) use atropine 10 – 30 mcg/kg IV followed by morphine sulphate 0.1 – 0.2 mg/kg IV and after 3-5 minutes suxamethonium 1.5 – 3 mg/kg IV; as neuromuscular paralysis develops commence hand ventilation and then intubate. A repeated dose of suxamethonium may be required occasionally and should be drawn up ready for use
  • sedation without paralysis using morphine sulphate 0.15 mg/kg IV and midazolam 0.15 mg/kg IV; it is important to wait at least 3 – 5 minutes for onset of effect. NOTE: Midazolam infusion has not been established as safe for use in very preterm infants. There have been reports of occurrence of dystonic reactions and seizures
  • at Monash Medical Centre the standard premedication sequence used is
  • for infants < 1000gm sedation with fentanyl 2microgm/kg (IV over 30 seconds)
  • for larger infants, fentanyl 2microgm/kg (IV over 30 seconds) followed by suxamethonium 2mg/kg IV over 10 to 30 seconds. Atropine (10microgm/kg over 1 minute) may be required if repeated doses of suxamethonium are used

A  laryngeal mask has been designed as a means of enabling assisted ventilation without actual passage of an ET tube through the vocal cords. This has not been fully evaluated in newborns or established yet as a standard practice.

go to top

References

Premedication for Neonatal Intubation K.J.Barrington, P.J.Byrne Am.J.of Perinatology 15,4,1998, 213-216

Nasal versus oral intubation for mechanical ventilation of newborn infants. Spence K, Barr P. Cochrane Database Syst Rev 2000

Intubating the Newborn, Judy A. Littleford. 1997. 32 minute videotape University of Manitoba, Health Sciences Book Store 140 Brodie Centre, 727 McDermot Ave, Winnipeg, Manitoba, Canada

Web links

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics. 2006 May;117(5):e978-88. Epub 2006

 

Please remember to read the disclaimer.
We welcome your Feedback.

 

webmaster. © RCH.