Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1).undefined#ref3">3
Intubation attempts should be limited to 30 seconds.1,2 Stabilize the patient with bag-mask ventilation between attempts to limit complications associated with the procedure.1
Avoid hyperoxygenation, hyperinflation, and hyperventilation.2
Applying cricoid pressure during oral intubation is no longer a recommended practice.7
Endotracheal (ET) intubation is a common procedure used to resuscitate patients in the delivery room and the neonatal intensive care unit. To reduce complications, the intubator should perform the procedure expeditiously in an environment that is as controlled as possible. In neonatal emergencies, oral intubation is the preferred route. Nasotracheal intubation is considered to allow more stable tube placement in the trachea and may be used for elective procedures, in patients with copious secretions, or when defects of the oral anatomy are present. Contraindications for nasotracheal intubation include increased risk of bleeding or nasal deformities (e.g., choanal atresia).8
Indications for ET intubation include:1,2,6
Routine tracheal suctioning of a nonvigorous, meconium-stained neonate is no longer recommended by the AHA.1 Tracheal suction is recommended only if evidence of an obstruction exists.1
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.1,2 Inserting the tube too far places the neonate at risk of injury to the carina or improper placement into the right mainstem bronchus. Weight-based estimation for proper insertion depth is no longer considered standard.5 Two methods are recommended for estimating the insertion depth: the nasal-tragus length (NTL) measurement or an estimation based on gestational age (Table 1). 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.1,2,4
ET intubation may be done via the nasal or oral route. The intubator’s skill and the patient’s clinical condition determine the route. If the nasal route is preferred, such as when facial deformities preclude intubation by the oral route, the process is more difficult and should be attempted only by a skilled intubator. In most cases, the oral route is selected over the nasal route. When the nasal route is used, the depth of insertion can be calculated based on the length of the patient, using the modified Morgan formula (ET tube position at the nares in cm = 0.12 × height [cm] + 5).5
Intubation attempts should take no longer than 30 seconds.1,2 If more than one intubation attempt is required, ventilation using a 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, oxygen should be administered and adjusted to maintain SpO2 readings at desired levels.1,2
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.
Potential complications of neonatal intubation include hypoxia from prolonged intubation attempts or insufficient supplemental oxygen; apnea and bradycardia caused by hypoxia or vagal stimulation; improper tube positioning (esophageal or right mainstem bronchus intubation); and trauma to the oropharynx, trachea, vocal cords, or esophagus.2
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.
For procedures that must be performed emergently: Comply with Universal Protocol only if it does not delay the procedure.
Oral intubation is the preferred route in neonatal emergencies.
2 monitoring as soon as possible. Evidence suggests that preterm neonates are susceptible to oxygen toxicity.
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.
Rationale: Intubation is a painful procedure associated with unfavorable physiologic effects such as bradycardia, desaturation, increased blood pressure, and increased intracranial pressure. Preintubation medication is associated with a decrease in the potential detrimental effects of intubation.
Rationale: A stylet inserted into the ET tube allows the intubator 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.
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.
Applying cricoid pressure during oral intubation is no longer a recommended practice.
Intubation attempts should be limited to 30 seconds.
1,2 Stabilize the patient with bag-mask ventilation between attempts to limit complications associated with the procedure.
Rationale: Asymmetric movement may indicate right mainstem intubation, esophageal intubation, or a pneumothorax.
Confirming ET tube placement may require eight to 10 positive-pressure breaths.
The effectiveness of the ET
2 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).
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.
Rationale: ET tube length of more than 4 cm beyond the lip increases dead space and may lead to tube kinking.
Nasal intubation is performed for elective procedures, in patients with copious secretions, or when the patient has defects of the oral anatomy.
Rationale: Gentle breaths reduce the air entering the stomach (leading to gastric distention), decrease airway turbulence, and distribute ventilation in the lungs more evenly.
Except for emergent intubation during resuscitation, either in the delivery room or after acute deterioration or critical illness at a later age, consider premedication for all intubations, preferably using medications with a rapid onset and short duration of action.
Rationale: A stylet inserted into the ET tube allows the intubator 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. Using aseptic technique preserves the cleanliness of the ET tube.
Rationale: An ET tube length of more than 4 cm beyond the naris increases dead space and may lead to tube kinking.
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.
Notify the practitioner of absent, decreased, or unequal breath sounds.
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.
Notify the practitioner of tube movement from the original position.
Notify the practitioner of an inability to pass a suction catheter; copious, frothy, or bloody secretions; or a significant change in amount or character of secretions.
Notify the practitioner of redness, necrosis, or skin breakdown.
Notify the practitioner of an inability to manage pain.
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
Cookies are used by this site. To decline or learn more, visit our cookies page.