Neonatal Intubation

Equipment

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Neonatal Intubation

Overview 

Neonatal intubation is a procedure used to secure the airway and provide ventilation support in newborns with respiratory distress, ensuring adequate oxygenation and airway protection, especially in critical situations like apnea, meconium aspiration, or hypoxic events. Always know your hospital’s policies and procedures on neonatal intubation before attempting.

 

1. Importance of Neonatal Intubation: 

Respiratory Support: 

  • Neonatal intubation is often performed to provide respiratory support to infants with compromised breathing, such as those with respiratory distress syndrome (RDS), meconium aspiration syndrome, or congenital anomalies. 

    Ventilation Control: 

  • Intubation allows for controlled ventilation, ensuring appropriate oxygenation and carbon dioxide elimination in neonates with respiratory failure. 

    Airway Protection: 

  • In certain cases, intubation is necessary to protect the airway and prevent aspiration, especially when there is meconium or other potential obstructions. 

2. Who should be intubated?

According to the Neonatal Resuscitation Program (NRP) guidelines, neonates should be intubated if they are not responding to positive pressure ventilation (PPV) with a mask and require advanced airway management. Other specific indications may include:

  1. Failure of Bag-Mask Ventilation: If effective ventilation cannot be achieved with a bag-mask due to airway obstruction, poor mask seal, or inadequate ventilation, intubation is indicated.

  2. Severe Respiratory Distress or Apnea: Neonates who are not breathing or have severe apnea and need continuous, controlled ventilation, particularly if the respiratory effort is inadequate or absent.

  3. Meconium Aspiration: If a neonate is born with meconium-stained amniotic fluid and is not vigorous (i.e., requiring resuscitation), intubation may be necessary for airway suctioning and to clear the airway. Routine intubation and suctioning of non-vigorous meconium stained babies is no longer indicated. This does not mean it cannot be performed. If an RT suspects meconium is blocking the airway and preventing the baby from ventilating or oxygenating, intubation and suctioning the trachea may be indicated.

  4. Cardiopulmonary Arrest: In cases of cardiopulmonary arrest or profound bradycardia despite adequate ventilation and chest compressions, intubation may be required for better airway control.

  5. Persistent Bradycardia: If the infant has persistent bradycardia (heart rate <60 bpm) despite adequate ventilation and chest compressions, intubation may be required to secure the airway for effective ventilation.

Disclaimer: Always follow physicians orders and know your hospitals policies before doing any procedure!

3. Anatomy and Physiology: 

Unique Neonatal Airway Anatomy: 

  • Neonates have anatomical differences, including a large tongue, a relatively large occiput, and a more anteriorly positioned larynx. Understanding these differences is crucial for successful intubation. 

    Nasal vs. Oral Intubation: 

  • The choice between nasal and oral intubation depends on the clinical scenario, patient condition, and individual factors. Check your hospitals policy on this.

 

 

 

4. Equipment and Preparation: 

a.Endotracheal Tubes (ETT): 

  • These are flexible tubes of various sizes designed for neonatal use. 

  • Size selection is critical, and the tube must be appropriate for the infant's age and weight. 

  • 2.5 ET tube for babies up to 1000g. 

  • 3.0 ET tube for babies 1000g – 2000g. 

  • 3.5 ET tube for babies 2000g – 3000g. 

    b.Laryngoscope: 

  • A laryngoscope is a device used to visualize the vocal cords and facilitate the insertion of the endotracheal tube. 

  • Neonatal laryngoscopes are smaller and have appropriately sized blades for newborns. 

  • 00 Blade for extremely low birth weight babies. 

  • 0 Blade for preterm babies. 

  • 1 Blade for term babies. 

c.Stylet: 

  • A stylet is a flexible metal wire that is used to shape the endotracheal tube and guide it through the vocal

    cords during intubation. The stylet should not extend past the end of the ET tube.  

    d. Suction Catheters: 

    Suction catheters are essential for removing any fluids or secretions from the airway before and after

    intubation. 

    e. Bag-Valve-Mask (BVM) Device: 

    A BVM device is used to provide positive pressure ventilation before and after intubation. 

    f. Oxygen Source: 

    Adequate oxygen supply is crucial during intubation and subsequent ventilation. Oxygen can be provided through a wall-mounted source or portable oxygen cylinders. 

    g.Resuscitation Equipment: 

    This may include equipment for neonatal resuscitation, such as a radiant warmer, cardiorespiratory monitors, and pulse oximeters. 

    h. End-Tidal or Colormetric CO2 Monitor: 

    Continuous monitoring of end-tidal CO2 helps confirm proper placement of the endotracheal tube. Colormetric CO2 devices ca also be helpful in assessing successful intubation.

    i.Tape and Securing Devices: 

    Adhesive tape or other securing devices are used to secure the endotracheal tube in place. 

    j. Stethoscope: 

    A stethoscope is used to confirm proper tube placement by auscultating breath sounds in the chest. 

    k. Sedation and Paralysis Medications: 

    Medications may be necessary to ensure the infant remains calm and still during the procedure. 

    l. Gloves and Sterile Drapes: 

    Healthcare providers should wear sterile gloves, and a sterile field should be established using drapes to minimize the risk of infection. 

 

It's important to note that neonatal intubation is a specialized skill that should be performed by trained healthcare professionals, such as neonatologists, pediatricians, or respiratory therapists, in a controlled and monitored environment. Always follow your hospital policies and procedures. Additionally, a thorough understanding of neonatal anatomy and proper techniques is essential to minimize the risks associated with this procedure. 

 

5. Techniques and Procedures: 

a. Pre-Intubation Assessment: 

  • Evaluate the neonate's respiratory status, assess the airway, and consider the need for preoxygenation

  • and premedication. 

    b. Positioning: 

  • Proper positioning, including sniffing position, helps align the airway for optimal visualization during laryngoscopy. 

    c. Laryngoscopy and Tube Insertion: 

  • Direct laryngoscopy involves lifting the epiglottis to visualize the vocal cords for tube insertion. Video laryngoscopy

    is an alternative technique. 

    d. Confirmation of Tube Placement: 

  • Employ multiple methods, including auscultation, chest rise, capnography, and bilateral breath sounds to confirm correct tube placement in the trachea. There are several methods for confirming appropriate ET tube depth but the quickest way is to add 6 to the weight in kg.  

    Example: If the baby weighs 0.5 kg, ET tube should be placed at 6.5 cm at the lip. This is just a guideline. You must still use assessment / CXR to confirm ET tube placement. 

  e. Assessment

  • Once you think the patient is intubated, look for chest rise when bagging, condensation in ET tube, bilateral breath sounds, colormetric CO2 change in color, and CXR placement. This will help you to confirm proper ET tube placement. Vital signs should remain stable if the ET tube is properly placed.

6. Complications and Troubleshooting: 

a. Complications: 

  • Potential complications include desaturation, bradycardia, trauma to the airway, and accidental extubation. 

  • If vocal cords are not open during intubation, try stimulating baby to breathe or cry to open cords. Do not attempt to forcefully put ET tube through closed cords. 

    b. Troubleshooting if intubation is difficult: 

  • It would be optimal to get O2 saturations within normal limits before starting intubation. This is not always possible in emergent situations.

  • Reposition baby. 

  • Raise the bed to a comfortable level. 

  • Try a different size laryngoscope. 

  • Suction Airway. 

  • Assess if sedation may be needed. 

  • Ensure ET tube size is appropriate. 

  • Try a different person who is trained. 

What do I do if intubation is not possible? 

  • Consider placing an LMA. Know your hospital's policy on using LMA. 

  • If all else fails, provide PPV with mask. Connecting capnometer during PPV is helpful in determining if adequate ventilation is being performed. 

  • Use a video laryngosope. Video laryngoscopy helps users directly visualize the intubation.