Neonatal Endotracheal Intubation

Key Points

• Time-critical procedure requiring skilled execution
• Success rates correlate with operator experience
• Maximum 30 seconds per attempt recommended
• Pre-procedure preparation is crucial
• Proper tube size and depth essential for successful ventilation

Indications

• Respiratory Failure
  • Respiratory distress syndrome
  • Meconium aspiration
  • Persistent pulmonary hypertension
  • Pneumonia
• Airway Protection
  • Depressed neurological status
  • Upper airway anomalies
  • Severe apnea
• Specific Conditions
  • Surfactant administration
  • Congenital diaphragmatic hernia
  • Tracheoesophageal fistula

Pre-Procedure Assessment

Patient Evaluation

• Clinical Assessment
  • Current respiratory status
  • Hemodynamic stability
  • Airway anatomy
  • Gestational age/weight
• Laboratory Values
  • Blood gases
  • Oxygen saturation
  • Blood glucose

ETT Size Selection

Weight-based guidelines:

• < 1000g: 2.5mm ID
• 1000-2000g: 3.0mm ID
• 2000-3000g: 3.5mm ID
• > 3000g: 3.5-4.0mm ID

Insertion Depth

Calculation methods:

• Weight-based: 6 + weight in kg
• Gestational age-based: Gestational age ÷ 10 + 5
• NLP (Nasal-Lip-Palate) measurement

Equipment & Preparation

Essential Equipment

• Airway Equipment
  • Laryngoscope with straight blades (Miller 00, 0, 1)
  • ETT tubes (multiple sizes)
  • Stylet (optional)
  • Suction catheters
  • End-tidal CO2 detector
• Monitoring Equipment
  • Pulse oximeter
  • Cardiac monitor
  • Temperature probe
• Ventilation Equipment
  • Bag-mask device
  • Oxygen source
  • Ventilator circuit
  • Humidifier

Medication Preparation

• Premedication (if time allows)
  • Vagolytic (Atropine 0.02mg/kg)
  • Sedation (if indicated)
  • Analgesic (if indicated)
  • Muscle relaxant (if indicated)
• Emergency Medications
  • Epinephrine
  • Volume expanders
  • Sodium bicarbonate

Procedure Technique

Positioning

• Sniffing Position
  • Neck slightly extended
  • Small roll under shoulders
  • Head midline
• Operator Position
  • Stand at head of bed
  • Adjust bed height for comfort
  • Ensure good visualization

Intubation Steps

1. Pre-oxygenation
   • Bag-mask ventilation with 100% oxygen
   • Ensure good chest rise
2. Laryngoscopy
   • Hold laryngoscope in left hand
   • Insert blade from right side of mouth
   • Advance to vallecula (Miller blade)
   • Lift forward and upward
3. Tube Insertion
   • Visualize vocal cords
   • Insert tube from right side
   • Advance to appropriate depth
   • Remove stylet if used
4. Confirmation
   • End-tidal CO2 detection
   • Chest rise
   • Breath sounds
   • Chest X-ray

Complications & Troubleshooting

Immediate Complications

• Physiological
  • Bradycardia
  • Hypoxemia
  • Cardiovascular collapse
  • Pneumothorax
• Traumatic
  • Oral/nasal trauma
  • Laryngeal injury
  • Tracheal perforation
  • Esophageal intubation

Late Complications

• Subglottic stenosis
• Vocal cord paralysis
• Tracheomalacia
• Infections

Troubleshooting

• Poor Visualization
  • Reposition head/neck
  • Suction secretions
  • Adjust lighting
  • Consider different blade size
• Failed Intubation
  • Resume bag-mask ventilation
  • Call for help
  • Consider LMA if available
  • Reassess technique

Post-Intubation Care

Immediate Care

• Secure ETT
  • Tape or securing device
  • Document depth at lip/nare
  • Mark reference point
• Ventilator Settings
  • Initial parameters based on condition
  • Monitor chest expansion
  • Adjust based on blood gases

Monitoring

• Continuous Assessment
  • ETT position
  • Breath sounds
  • Oxygen saturation
  • Vital signs
  • Work of breathing
• Regular Checks
  • ETT secureness
  • Circuit integrity
  • Humidification
  • Oral care