Endotracheal Tube Intubation: Assisting (Neonatal) - CE/NCPD

ALERT

Intubation attempts should be limited to 30 seconds.^{undefined#ref1">1,2,3} Stabilize the patient with bag-mask ventilation between attempts to limit complications associated with the procedure.²

Avoid hyperoxygenation, hyperinflation, and hyperventilation.³

OVERVIEW

Endotracheal (ET) intubation is a common procedure used to establish a secure airway in a neonate who is in respiratory failure or exhibiting signs of impending respiratory failure. Intubations are performed in the delivery room, neonatal intensive care unit, and operating room. To reduce complications, the health care team member intubating the infant should perform the procedure expeditiously in an environment that is as controlled as possible. In neonatal emergencies, oral intubation is the preferred route because it is easier, faster, and less traumatic to perform, especially in an emergency.⁴

Indications for ET intubation include:

• Acute or impending respiratory failure with impaired oxygenation or ventilation as indicated by increasing respiratory distress or abnormal blood gas values (high carbon dioxide levels, low pH)⁷
• Positive-pressure ventilation when bag-mask ventilation is ineffective or prolonged mechanical respiratory support is required^1,3,6
• Administration of exogenous surfactant or medications in the emergency setting before IV access is established³
• Critical upper airway tract obstruction (e.g., subglottic stenosis)^1,3,6
• Frequent, clinically significant apneic episodes that are unresponsive to conventional therapy
• Airway abnormalities that interfere with ventilation (e.g., Pierre Robin syndrome)^1,3,6
• Diaphragmatic hernia^1,3,6
• Elective intubation prior to surgery⁷
• Suctioning bronchopulmonary secretions or obtaining a direct tracheal culture specimen³

Routine tracheal suctioning of a nonvigorous, meconium-stained neonate is no longer recommended by the American Heart Association (AHA).² Tracheal suction is recommended only if evidence of an obstruction exists.²

Intubation is a two-person procedure. The assistant provides free-flow oxygen, monitors heart rate and peripheral oxygen saturation (SpO₂), and suctions if airway secretions interfere with observation.

Proper placement of an ET tube in a neonate is challenging. Proper placement generally is only 1 to 2 cm past the vocal cords.^1,3 Inserting the tube too far places the neonate at risk of injury to the carina or improper placement into the right mainstem bronchus. Methods recommended for estimating the insertion depth include: the nasal-tragus length (NTL) measurement, estimation based on gestational age (Table 1), or weight-based estimation (7-8-9 Rule).⁵ The NTL method is validated for both preterm and term neonates and uses a calculation based on the distance in centimeters from the neonate’s nasal septum to the ear tragus. The estimated insertion depth is the NTL measurement plus 1 cm.^1,3 Weight-based estimation (7-8-9 Rule) the proper insertion depth is calculated by adding 6 to the patient’s weight in kilograms.⁵ This method has been noted to overestimate insertion depth on extremely low birth weight infants (ELBW) weighing less than 750 g, thus the preferred method for estimating the insertion depth is the NTL measurement and gestational age estimation (Table 1).^1,3,4

Intubation attempts should take no longer than 30 seconds.^2,3 If more than one intubation attempt is required, ventilation using a self-inflating resuscitation bag, flow-inflating resuscitation bag, or a T-piece resuscitator with a tight-fitting face mask should be performed before each subsequent attempt until the patient recovers. The concentration of oxygen used during resuscitation depends on the patient’s gestational age, chronologic age, and response to resuscitation. Excessive oxygen may cause oxidative stress and further compromise the patient. If resuscitation is initiated without the use of oxygen and no improvement is seen, blended oxygen should be administered and adjusted to maintain SpO₂ readings at desired levels.^1,3,6

Two types of laryngoscope blades exist, straight and curved. The straight blade is preferred for neonatal intubation. The size of the blade is based on the patient’s weight (Table 2).

ET tube size reflects the size of the internal diameter of the tube. The most commonly used ET tubes for neonates range from 2.5 mm to 3.5 mm (Table 3).¹ The ET tube with the largest clinically acceptable internal diameter should be used to minimize airway resistance and air leaks and to facilitate suctioning.

ET tubes used for neonatal intubation are not tapered or cuffed to eliminate pressure on the airway that may predispose the patient to necrosis. The absence of a cuff makes the ET tube prone to dislodgment; thus, securement is vital.^3,4,5

Potential complications of neonatal intubation include:^3,5

• Hypoxia from prolonged intubation attempts or insufficient supplemental oxygen
• Apnea
• Bradycardia caused by hypoxia or vagal stimulation
• Improper tube positioning (esophageal or right mainstem bronchus intubation)
• Accidental or unplanned extubation
• Trauma to the oropharynx, trachea, vocal cords, or esophagus, such as perforation or bleeding
• ET tube occlusion
• Infections associated with inserted ET tube
• Subglottic stenosis from prolonged intubation

All supplies and equipment necessary for intubation should be checked on a regular basis to ensure that they are in working order before the procedure is initiated. These supplies and equipment should be kept together on either a resuscitation cart or an intubation tray close to the patient’s bedside.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the procedure and the reason for intubation, if the clinical situation permits. If time does not permit, explain the procedure and the reason for the intubation after the procedure.
• Explain that because the ET tube passes through the vocal cords, cries from the patient will not be audible while the ET tube is in place.
• Provide information about neonatal procedural pain assessment and management, including the benefits and risks of pharmacologic and nonpharmacologic options.³
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the family.
3. Verify the correct patient using two identifiers.
4. Assess the family’s understanding of the reasons for and risks and benefits of the procedure.
5. Determine the family’s desire to be present during the procedure.
6. Assess the patient for facial deformities that preclude oral intubation.

Preparation

1. Comply with Universal Protocol. Use a standardized list to verify that all required items, including informed consent, are available.

   For procedures that must be performed emergently: Comply with Universal Protocol only if it does not delay the procedure.

2. Notify the respiratory therapy department, if not already present, of the impending intubation so they are available to assist and get the appropriate ventilator set up.
3. Determine the appropriate-size equipment (laryngoscope blade and ET tube) based on the patient’s weight and gestational age before initiating the procedure (Table 2) (Table 3).
4. Inspect the laryngoscope to ensure that the light is functioning properly. Change the batteries or bulb, if needed.
5. Ensure that the resuscitation bag or T-piece resuscitator is functioning properly, select an appropriate-size mask for ventilation, and verify an attachment to a 100% oxygen source with the blender set minimally at a flow rate of 5 to 10 L/min.³
6. Prepare the suction source set at 60 to 100 mm Hg of negative pressure and suction catheter (size 10 or 12 Fr) as appropriate.^1,6
7. If anticipating intubation at delivery, have a meconium aspirator present if meconium fluid is noted during delivery.³
8. Determine the appropriate ET tube insertion depth.¹ The tip should be 1 to 2 cm below the vocal cords.^3,4
   1. For oral intubation, use one of three methods:
      1. NTL measurement: The depth of the tube at the gums in centimeters should be equal to the measurement from the nasal septum to the tragus of the ear plus 1 cm.^1,3
      2. Gestational age: This method uses the gestational age to predict the correct insertion depth (Table 1).¹
      3. The 7-8-9 rule: This method adds 6 to the patient’s weight in kilograms.^3,4,5

PROCEDURE

Oral Intubation

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment, if time allows.
4. Minimize heat loss by placing the patient in an appropriate environment that provides thermal homeostasis.
5. Ensure appropriate monitoring of the patient’s heart rate and SpO₂ continuously during the procedure.

   Begin SpO₂ monitoring as soon as possible. Evidence suggests that preterm neonates are susceptible to oxygen toxicity.²

6. If time permits, comply with Universal Protocol. Perform a time-out to verify the correct patient, correct site, and correct procedure.
7. Preoxygenate the patient with the appropriate oxygen concentration to achieve SpO₂ levels in the desired range. Use a mask, flow-inflating bag device, or free-flow oxygen tubing if ventilations are adequate. If the patient is not adequately ventilating, use a self-inflating or flow-inflating resuscitation bag-mask or T-piece device to ventilate the patient manually.³
   1. Maintain the respiratory rate between 40 and 60 breaths per minute.^1,6
   2. Limit the pressure of administered breaths to the minimum required to produce an easy rise and fall of the chest.
   3. Monitor the patient for an improvement in heart rate, color, SpO₂, and tone.^1,6

      Rationale: Monitoring helps identify early signs of hypoxemia or hyperoxemia. Gentle breaths reduce the air entering the stomach (leading to gastric distention), decrease airway turbulence, and distribute ventilation in the lungs more evenly.

      If the patient is breathing, avoid positive-pressure ventilation because of the risk of gastric distention, aspiration, and vomiting.

      Place an 8-Fr orogastric tube to remove air and stomach contents if the patient requires resuscitation with bag-mask ventilation for longer than 2 minutes.¹

8. Premedicate the patient as prescribed and provide nonpharmacologic interventions.

   Rationale: Intubation is a painful procedure associated with unfavorable physiologic effects such as bradycardia, desaturation, increased blood pressure, and increased intracranial pressure. Premedication in nonemergent neonatal intubation is associated with a decrease in the potential detrimental effects of intubation and significantly improves conditions for the procedure by promoting jaw relaxation, opening and immobilizing vocal cords, and suppressing pharyngeal and laryngeal reflexes.⁶

9. Obtain the appropriate ET tube and laryngoscope blade (Table 2) (Table 3).
10. If a stylet is needed, insert it into the ET tube, using aseptic technique.^1,4

    Rationale: A stylet inserted into the ET tube allows the health care team member intubating to control the direction of the tube. Keeping the stylet from extending past the end of the tube prevents damage to the vocal cords and trachea.

    Do not let the stylet tip extend beyond the end of the ET tube.

11. Assist with positioning the patient supine with the patient’s head midline with the neck slightly extended (sniffing position) (Figure 1). If necessary, place a small roll under the patient’s shoulders and contain the arms as needed.¹

    Rationale: Slight extension of the patient’s neck aligns the mouth, pharynx, and trachea for a better view of the vocal cords.

    Avoid hyperextending the neck or rotating the head, which makes the vocal cords difficult to see.³

12. Hold the equipment so the health care team member intubating does not need to look away from anatomic landmarks to suction secretions or grasp the tube for intubation.
13. Hand the ET tube to the health care team member intubating when requested, maintaining the sterility of the tube. Observe as the team member intubating places the tube into the airway and visually verifies placement.

    Intubation attempts should be limited to 30 seconds.^2,3 Stabilize the patient with bag-mask ventilation between attempts to limit complications associated with the procedure.²

14. After the tube is correctly placed, read the centimeter mark on the ET tube at the patient’s gums. The estimated depth of insertion is based on the gestational age or the NTL plus 1 cm.³
15. Connect the ET tube to a disposable end-tidal carbon dioxide (ETCO₂) detector, the oxygen source, a flow- or self-inflating resuscitation bag-mask device, and a T-piece resuscitator or mechanical ventilator to provide positive-pressure ventilation.¹
16. Verify tube placement while a team member ventilates and oxygenates the patient.³
    1. Immediate methods of verification include:
       1. Observe the chest for symmetric movement with each breath.

          Rationale: Asymmetric movement may indicate right mainstem intubation, esophageal intubation, or a pneumothorax.

       2. Auscultate bilateral breath sounds near both axillae during positive-pressure ventilation.
    2. Confirmatory methods, which can be used after a few seconds of manual ventilation, include:
       1. Check for an increase in heart rate and SpO₂ if bradycardia and hypoxia were present before the procedure.
       2. Observe the ETCO₂ detector for a change in color.

          Confirming ET tube placement may require eight to 10 positive-pressure breaths.²

          The effectiveness of the ETCO₂ detector is limited. Proper placement may not produce a color change if heart rate or cardiac output is low or the lungs are not adequately ventilated (i.e., secretions obstructing the ET tube, inadequate ventilator pressure, or large bilateral pneumothoraces).²

17. If auscultation reveals unilateral or unequal breath sounds, notify the health care team member intubating and observe as the tube is withdrawn slowly until equal bilateral breath sounds are auscultated.¹
18. If auscultation detects no breath sounds or detects air entering the stomach and no color change is seen on the ETCO₂ detector, notify the health care team member intubating and prepare to repeat the procedure with a new ET tube after stabilizing the patient with bag-mask ventilation, if necessary.¹
19. After immediate and subsequent confirmation of ET tube position, document the centimeter mark at the gums and secure the tube. Place a skin barrier, such as a hydrocolloid dressing, between the adhesive tape and the skin.³

    Rationale: The lips may swell, leading to variation in the ET tube measurement. The gums are a more reliable landmark.

    Maintain the tube in the correct position throughout the procedure.

20. Obtain an anteroposterior view chest radiograph with the patient’s head at the midline for definitive confirmation of the ET tube placement. Ensure that the tip of the ET tube is approximately 0.5 to 1 cm above the carina.³
21. Cut off any length of tube that extends more than 4 cm beyond the patient’s lip.³

    Rationale: ET tube length of more than 4 cm beyond the lip increases dead space and may lead to tube kinking.³

22. Insert an 8-Fr orogastric tube to remove air and stomach contents if gastric distention is present.⁶
23. Discard supplies, remove PPE, and perform hand hygiene.
24. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient’s vital signs frequently before, during, and after the procedure.

   Rationale: Any change in vital signs may indicate airway compromise from incorrect ET tube position, dislodgment, or obstruction.

   Notify the practitioner of bradycardia, hypertension or hypotension, apnea or abnormal respirations, or decreased SpO₂ from the patient’s baseline value.

2. Auscultate breath sounds with any change in respiratory status and when providing hands-on care.

   Notify the practitioner of absent, decreased, or unequal breath sounds.

3. Maintain ET tube stability using a commercially available securement device or adhesive tape.

   Notify the practitioner of audible crying, unplanned extubation, or tube movement from the original position. Remove the tube and begin bag-mask ventilation as appropriate.

4. Monitor and record the position of the ET tube at the patient’s gums on insertion and with hands-on care.

   Notify the practitioner of tube movement from the original position.

5. Suction the ET tube, as needed.

   Notify the practitioner of an inability to pass a suction catheter; copious, frothy, or bloody secretions; or a significant change in volume or character of secretions.

6. Inspect the oral cavity every time hands-on care is provided while the patient is intubated.

   Notify the practitioner of redness, necrosis, or skin breakdown.

7. Perform regular oral care using sterile 0.9% sodium chloride solution or breast milk.
8. Assess, treat, and reassess pain.

   Notify the practitioner of an inability to manage pain.

EXPECTED OUTCOMES

• Correct placement of patent ET tube
• Properly positioned and secured airway
• Improved oxygenation and ventilation
• Facilitation of secretion clearance
• Stabilization of patient

UNEXPECTED OUTCOMES

• Improper tube placement (intubation of esophagus or right mainstem bronchus)
• Accidental extubation
• Cardiac arrhythmias from hypoxemia or vagal stimulation
• Injury to lips or gums
• Air leakage from around the ET tube
• Tracheal injury at tip of tube
• Laryngeal edema
• Vocal cord trauma
• Suctioning of gastric contents or food from ET tube
• Obstruction of ET tube
• Ventilator-associated pneumonia
• Pneumothorax
• Laceration of tongue, gums, or airway
• Perforation of trachea and esophagus

DOCUMENTATION

• Education
• Vital signs and SpO₂ before, during, and after intubation
• Time-out procedure, including verification of the correct patient, correct procedure, and correct site (if performed)
• Type and size of blade used
• Number of intubation attempts
• Medication administration
• Size of ET tube
• Depth of ET tube insertion (centimeter mark at patient’s gums)
• Assessment of breath sounds
• Confirmation of tube placement with breath sounds and ETCO₂ detector
• Confirmation of tube placement by chest radiograph
• Color, volume, and consistency of secretions
• Patient’s response to procedure
• Unexpected outcomes and related interventions
• Pain assessment, interventions, effectiveness of interventions, and adverse reactions

REFERENCES

1. American Academy of Pediatrics (AAP), American Heart Association (AHA). (2021). Lesson 5: Endotracheal intubation. In G.M. Weiner and others (Eds.), Textbook of neonatal resuscitation (8th ed., pp. 117-157). Itasca, IL: AAP. (Level VII)
2. Aziz, K. and others. (2020). Part 5: Neonatal resuscitation: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S524-S550. doi:10.1161/CIR.0000000000000902 Retrieved January 3, 2024, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000902 (Level I)
3. Bailey, T.B., Maltsberger, H.L. (2021). Chapter 15: Common invasive procedures. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 244-269). St. Louis: Elsevier. (Level VII)
4. DiBlasi, R. (2022). Chapter 29: Respiratory care of the newborn. In M. Keszler, K. Suresh Gautham (Eds.), Goldsmith’s assisted ventilation of the neonate: An evidence-based approach to newborn respiratory care (7th ed., pp. 363-383). St. Louis: Elsevier. (Level VII)
5. El-Atawi, K., Kumar Dash, S., Zakaria Elmorsy, A. (2019). Chapter 37A: Neonatal procedures involving catheters and tubes. In P.K. Rajiv, D. Vidyasagar, S. Lakshminrusimha (Eds.), Essentials of neonatal ventilation (pp. 803-818). St. Louis: Elsevier. (Level VII)
6. Pappas, B.E., Robey, D.L. (2021). Chapter 5: Neonatal delivery room resuscitation. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 69-85). St. Louis: Elsevier. (Level VII)
7. Stein, M.L., Thomas, M, Watters, K. (2023). Chapter 36: Airway management. In B. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 609-631). Philadelphia: Elsevier. (Level VII)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: February 2024