management of the neonatal airway based upon american academy for pediatrics (aap) guidelines...

Management of the Neonatal AirwayBased upon American Academy for Pediatrics (AAP) Guidelines

Presented by:• Michael R. Jackson RRT-NPS CPFT• & the NRP Instructors* of the NICU Respiratory Care Service

* AAP Certified Instructors of the Newborn Resuscitation Program

32 weeks & under

Oral airway•Used for:

•Micrognathia (pictured here)

•Pierre Robin•Choanal atresia

•airway may cause gagging

Oral airway•Predict size measure from ear to corner of mouth•Placed right side up in the oropharynx (no need to rotate into place as with adult oral airways)

Choanal Atresia

Lesson 3: Insertion of Orogastric Tube

Measuring correct length

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Pressure/Volume

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Nasopharangeal Tube for CPAPNasal tubes • more easily secured in position than oral tube•Are associated with nasopharangeal irritation, swelling, mucous plugging•Greater movement in airway with head motion than oral tubes•Require greater (~1cm) insertion depth than oral tube

Nasotracheal Tube for VentilationNasal tubes • more easily secured in position than oral tube•Are associated with nasopharangeal irritation, swelling, mucous plugging•Greater movement in airway with head motion than oral tubes•Require greater (~1cm) insertion depth than oral tube

DuoDerm•Nare protection from CPAP prongs•Nasal seal for CPAP prongs

ResidentsSuccess Rate at intubation

1st year 33%2nd or 3rd year 40%Fellows 68%Rate for those with experience <20 37%Rate for those with experience >20 49%

Leone TA, Rich W, Finer NN, Neonatal Intubation Success of Pediatric Trainees, J Pediatr 2005;146:638-641

Preferred number of experiences to achieve competency is 45. Opportunities have diminished since we stopped intubating active meconium babies.

Rates of Intubation Success

AAP Newborn Resuscitation: Endotracheal Intubation Indications

Meconium present and baby is not vigorous

Prolonged positive-pressure ventilation required

Bag-and-mask ventilation ineffective

Chest compressions necessary

Epinephrine administration necessary

Special indications: prematurity, surfactant administration, diaphragmatic hernia

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

E

T

TUBE

Neck mass •by ultrasound•During EXIT* procedure*ex utero intrapartum treatment

Surfactant &Surfactant &Tube positionTube position

•90 degree ETT to airway entrance•Blue line of ETT superior

Equipment and Supplies

Equipment should be clean, protected from contamination. Wear gloves

Sterile disposable endotracheal tubes with uniform diameters preferred. Size is based on gestational age.

Stylette is optional

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

ETT Size ETT Size Wt. Gest.Wt. Gest. (mm)(mm) (kg) (wks)(kg) (wks)

2.5 < 1 <282.5 < 1 <28

3.03.0 1 – 2 28-34 1 – 2 28-34

3.53.5 2 - 3 34-38 2 - 3 34-38

Lesson 5: Preparation of Laryngoscope: Supplies

Select blade size– No 0 for preterm newborns

– No 1 for term newborns

Check laryngoscope light

Connect suction source to 100 mm Hg

Use large suction catheter (greater than or equal to 10F) for secretions

Small suction catheter for ET tube

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Anatomic Landmarks

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Flash intubation http://www.brighamandwomens.org/respiratorytherapy/Images/intube.swf

Positioning the Newborn Prepare for IntubationPositioning the Newborn Prepare for Intubation

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Prepare resuscitation bag and mask

Turn on oxygen

Get stethoscope

Cut tape or prepare endotracheal tube stabilizer

Flash intubation http://www.brighamandwomens.org/respiratorytherapy/Images/intube.swf

Lesson 5: Endotracheal IntubationStep 1: Preparation for Insertion

Stabilize head

Provide free-flow oxygen

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Lesson 5: Endotracheal Intubation:Holding the Laryngoscope

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Lesson 5: Endotracheal IntubationStep 2: Insert Laryngoscope

Slide blade over right side of tongue

Push tongue to left side of mouth

Advance blade tip to vallecula

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Lesson 5: Endotracheal IntubationStep 3: Lift Blade

Lift blade up & away

keep handle @ 60 degrees to baby’s chest

Visualize pharyngeal area

Do not use rocking motion

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

60

Visualize Landmarks

Vocal cords appear as vertical strips or as inverted letter “V”

Downward pressure on cricoid may help bring glottis into view

May need to suction secretions

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Pass tube from right side of mouth (not down blade – which would obstruct view)

Hold tube inright hand

Insert until cord guideis at cords

Wait for cords to open

Limit attempt to 20 seconds

Tube Location in Trachea

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Remove Laryngoscope

Use a finger to hold the tube against the hard palate

Remove laryngoscope (and stylet, if used)

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Signs of correct tube position

Chest rise with each breath

Breath sounds over both lung fields

No gastric distention with ventilation

Vapor condensing on inside of tube during exhalation

Carbon dioxide detector will change color (or reads more than 2%-3% during exhalation)

Depth of insertionDepth of insertionWeightWeight (kg)(kg) (cm from upper lip)(cm from upper lip)

.50.50 66

.75.75 6.56.5

1*1* 77

22 88

33 99

44 1010

Predicted Tube Location in Trachea

Tip-to-lip measurement

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

The fulcrum for movement of this lever arm is the upper cervical spine.

Fulcrum for movement of thislever arm is the upper cervical spine..

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VocalCord

VocalCord

Epiglottis

Thy. Cartilage

Thy. Cartilage

Epiglottis

FLEXION NEUTRAL EXTENSION

ETCO2 display

On/off

Respiratory Rate Display

1Place sensor & turn unit on. Place sensor & turn unit on. (unit will self-test)Confirm position by·        CO2 value (ideally > 20)·        CO2 waveform on monitor

Figure 1. Sensitivity = 94%, Specificity = 98%, P P Value = 98% , N P Value = 94%

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•False positive (tube in esophagus)•technical error.

•False negative (tube in trachea CO2 reading low)

•severe bronchospasm, •hyperventilation, •technical error, •huge leak around ett, •cardiopulmonary arrest.

Where is

the tube?

esophagealintubation

Every few years, another BPD baby requiresa trach at Brigham & Women’s Hospital.

Bivona 3.0 TTS Custom FlexTend

cuff

Water port

Pilot balloon

stylette

Airwayconnect

•Suction at least a few mm past the length of trach tube –pre-measure distance to suction

Trach Suction

Trach Feeding• Assess ability of patient to

coordinate suck, swallow & breathe

• Test swallowing ability ~ 5 days after tracheostomy- (maybe earlier)

Changing a trach tube

Humidification

• Remove stitches On new trach tube

• Remove tracheostomy tube

• Insert new tube same size

•Monitor # of “noses”used per day

•Check if patient is aspirating saliva

•Frequent coughing may be a clue