ENDOTRACHEAL ENDOTRACHEAL INTUBATIONINTUBATION

NEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHMNEONATAL FLOW ALGORITHM

BIRTHBIRTHBIRTHBIRTH

• Term gestation?• Amnlotic fluid clear?• Breathing or crying?• Good muscle tone?u

• Term gestation?• Amnlotic fluid clear?• Breathing or crying?• Good muscle tone?u

• Provide warmth• Position clear airway* (as necessary)• Dry, stimulate, reposition

• Provide warmth• Position clear airway* (as necessary)• Dry, stimulate, reposition

Routine Care• Provide warmth• Clear airway if needed• Dry• Assess color

Routine Care• Provide warmth• Clear airway if needed• Dry• Assess color

Evaluate respiration heart rate and colorEvaluate respiration heart rate and color

Give supplementary oxygen

Give supplementary oxygen

Observational CareObservational Care

Provide positive-pressure ventilation*Provide positive-pressure ventilation* Post-resuscitation carePost-resuscitation care

• Provide positive-pressure ventilation*

•Administer chest compression

• Provide positive-pressure ventilation*

•Administer chest compression

Administer epinephrine and/ or volume*Administer epinephrine and/ or volume*

* Endotracheal intubation may be considered at several steps

* Endotracheal intubation may be considered at several steps

HR <60

HR <60 HR >60

Persistent cyanosis Effective

Ventilation, HR>100 & Pink

Pink Breathing, HR>100

but cyanosis

Breathing, HR>100 & Pink

Yes

No

Apneic or HR <100

Approximate Time

30 sec

30 sec

30 sec

Indications for Indications for intubationintubation

Meconium suctioning in non vigorous Meconium suctioning in non vigorous babybaby

Diaphragmatic herniaDiaphragmatic hernia Prolonged PPVProlonged PPV Ineffective B & MVIneffective B & MV ElectiveElective

< 1Kg< 1Kg with CCwith CC for medicationfor medication

Intubation equipmentIntubation equipment

Preparing laryngoscopePreparing laryngoscope

No. 1 for full termNo. 1 for full term No. 0 for preterm / LBWNo. 0 for preterm / LBW No. 00 for extremely preterm No. 00 for extremely preterm

(optional)(optional)

Selecting endotracheal Selecting endotracheal tubetube

Tube SizeTube Size WeightWeight Gest. AgeGest. Age

2.5 (ID mm)2.5 (ID mm) <1000 gm<1000 gm < 28 wks< 28 wks

3.0 (ID mm)3.0 (ID mm) 1000-2000 1000-2000 gmgm

28-34 wks28-34 wks

3.5 (ID mm)3.5 (ID mm) 2000-3000 2000-3000 gmgm

35-38 wks35-38 wks

4.0 (ID mm)4.0 (ID mm) >3000 gm>3000 gm > 38 wks> 38 wks

ID=Internal Diameter

Preparing endotracheal Preparing endotracheal tubetube

Shorten the tube to 13 cmShorten the tube to 13 cm Replace ET tube connectorReplace ET tube connector Insert stylet (optional)Insert stylet (optional)

Additional itemsAdditional items

TapeTape For securing the tubeFor securing the tube

Suction equipmentSuction equipment DeLee mucus trap or mechanical suctionDeLee mucus trap or mechanical suction

OxygenOxygen For free flow oxygen during intubationFor free flow oxygen during intubation For Use with the resuscitation bagFor Use with the resuscitation bag

Resuscitation Bag and MaskResuscitation Bag and Mask To ventilate the infant in between intubationTo ventilate the infant in between intubation To check tube placementTo check tube placement

Positioning the infantPositioning the infant

On a flat surface, head in midline On a flat surface, head in midline and neck slightly extendedand neck slightly extended

Optimal viewing of glottisOptimal viewing of glottis

Visualizing the Glottis with Visualizing the Glottis with LaryngoscopeLaryngoscope

Preparing for insertionPreparing for insertion Stand at the head end of the infantStand at the head end of the infant

Hold the laryngoscope in your left handHold the laryngoscope in your left handStabilize the infant’s head with right handStabilize the infant’s head with right hand

Introducing BladeIntroducing Blade Slide it over the tongue with the tip of the blade resting Slide it over the tongue with the tip of the blade resting

on the valleculaon the vallecula

Visualizing Glottis : Lift BladeVisualizing Glottis : Lift Blade Lift it slightly, thus lifting the tongue out of the way to Lift it slightly, thus lifting the tongue out of the way to

expose the pharyngeal areaexpose the pharyngeal area

Vocal cord guideVocal cord guide

Tip to lip distance Tip to lip distance (6+wt. in kg)(6+wt. in kg)

WeightWeight DistanceDistance

1 kg1 kg 7 cm7 cm

2 kg2 kg 8 cm8 cm

3 kg3 kg 9 cm9 cm

Confirming ET tube Confirming ET tube placementplacement

Correct placementCorrect placement ETCOETCO2 2 - the recommended method - the recommended method

SignsSigns Bilateral breath soundsBilateral breath sounds Equal breath soundsEqual breath sounds Rise of the chest with each ventilationRise of the chest with each ventilation No air heard entering stomachNo air heard entering stomach No gastric distentionNo gastric distention

Confirmation of tip position in Confirmation of tip position in tracheatrachea

Chest X-ray: tip at TChest X-ray: tip at T22

Tube in Rt. Main Tube in Rt. Main bronchusbronchus

Breath sounds only on right Breath sounds only on right chestchest

No air heard entering stomachNo air heard entering stomach No gastric distentionNo gastric distention

Action: Withdraw the tube, recheckAction: Withdraw the tube, recheck

Tube in esophagusTube in esophagus

No breath sounds heardNo breath sounds heard Air heard entering stomachAir heard entering stomach Gastric distention may be seenGastric distention may be seen No mist in tubeNo mist in tube No CONo CO2 2 in exhaled airin exhaled air

Action : Remove the tube, oxygen the infant Action : Remove the tube, oxygen the infant with a bag and mask, reintroduce ET tubewith a bag and mask, reintroduce ET tube

Three actions after Three actions after intubationintubation

1.1. Note the cm. Mark on the Note the cm. Mark on the tube at level of the upper liptube at level of the upper lip

2.2. Secure the tube to the infant’s Secure the tube to the infant’s faceface

3.3. Shorten tube 4 cm. from the Shorten tube 4 cm. from the lip marginlip margin

Complications of Complications of intubationintubation

HypoxiaHypoxia

BradycardiaBradycardia

ApneaApnea

PneumothoraxPneumothorax

Soft tissue injurySoft tissue injury

InfectionInfection

Minimizing hypoxia Minimizing hypoxia during intubationduring intubation

Providing free-flow Providing free-flow oxygen (Assistant’s oxygen (Assistant’s responsibility)responsibility)

Limiting each Limiting each intubation attempt to intubation attempt to 20 seconds20 seconds

LMA – its role in neonatal LMA – its role in neonatal resuscitationresuscitation

Effective for ventilation during Effective for ventilation during resuscitation in term and near term resuscitation in term and near term newbornsnewborns

Used by trained care providersUsed by trained care providers NOT TO BE USED IN:NOT TO BE USED IN:

In the setting of meconium stained amniotic In the setting of meconium stained amniotic fluidfluid

When chest compression is requiredWhen chest compression is required In VLBW babiesIn VLBW babies For delivery of medicationsFor delivery of medications